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" J APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED Y (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address I• 93 r' -Q f City t Siz PM OwnerLs.Name. " % �� Address ` i � Phone License No. oAddress g 10 PhoneContracto I TYPE OF WELL-/PUMP:. 2. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. - PROP. LINE F FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing { ❑ Domestic/Private IDGravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I i Irrigation _-.Approx. Depth I I Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction El Well Diameter Sealing Material Itop 50'1 a Depth Materia! {Belo 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.l•. REPAIR DDITION I_ _DEST'RUCTION,,I'1 Ilya septic system permitted if public sewer is available within 200 feet.) ' Installation will serve: Residence_ Commercial Other ,gam Number of living units: -- l —� Number of edrooms""""` ry Character of soil to a depth of 3 feet: r Water table depth (420 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 5 PKG.-TREATMENT PLT. ❑ Method of Disposal y� Distance to neare'stf Well �- Foundatiori' '- Property Line LEACHING LINE Lf No. & Length of Cines Total length/size x FILTER Off) - --.9—Distance to-nearest:. - Well Foundation 07 Q f >3 Property Line ,_ e SEEPAGE PITS I I� Depth SizeX Number SUMPS [A' Distance to nearest: (Nell-J-0-6-' `Mn -----•-Foundation..__._�(� Property Line tMSPOSAL PONDS ❑ A I herebV.certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,.and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not " employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature ! certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws'b'f California." The applicant us all for Mqui inspections. Complete drawing on raver e Signed X Title: t T Date. FDEPARTM T USE ONLY di r s} I Application Accepted by Date � �*� Area 4 or out Inspecti by 44,10R Final Inspection by ataa�ax� , Add ronai Orr arts nts; ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a I FEE AMOUNT DUEAMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, INFO CASH + EH13.24;REV.1/H51 4-20 EH I 1.