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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES '!'YEAR FROM DATlw ISSUED . I (Complete in Triplicate) r € 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 Ile- City Lot Size PM Owner's Name Address Phone i Contractor Address ) �� f �'ITd.4 License No.��t5Phone TYPE OF WELL PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ —PUMP _.. SYSTEM REPAIR..❑ _ .,.OTHER.❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 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 k- ❑ Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing Specifications $' { 1'1 Public ❑ Other Cl'delta Depth of Grout Seat Type of Grout ! I i I Irrigation _-Approx, Depth l I Eastern Surface Seal Installed by I" Repair Work Done ❑ Type of Pump H.P,' State Work Done _ Well Destruction -0 Well Diameter Sealing Material Itop 501. Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION') REPAIR/ADCrITION l I DESTRUCTION l I (No septic system permitted it public sewer is t # available within 204 feet.) Installation will serve: Residence_k� Commercial_ Other r Number of living units: Number of bedrooms ` a Character of soil to a depth of 3 feet: _, b 4 13ti:-� + ¢ - _ Water table depth �. SEPTIC TANK ❑ Type/Mfg ' CapacityG?31- No. Compartments = PKG. TREATMENT PLT- ❑ Method of Disposal ' Distance to nearest=' Well' L� Foundation Property Line LEACHING LINE r' No. & Lengthaof fines 5 _�ssG7 'E Total length/size FILTER BED _ ❑ Distance to nearest: Well Foundationpr Property Line SEEPAGE PITS 11 Depth !'.9ISize _^ Number : SUMPS Distance to nearest: Well` ` Founda on L P operty Line DISPOSAL PONDS ❑ ,- ' r * ! I hereby certify that I have prepared this application and that the'viork wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin,Local Health Di§trict. r 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 i employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature t„. 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 of California.” f, The applicant must cal( for all required inspections. Complete drawing on reverse side. 1 Signed X' Title: .. ..� 't• Date: FOR D ART USE ONLY ..R /Application Accepted by abate / '� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments; N - — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 S ' INFO AMOUNT DUE AMOUNT REMITTED r CA3y "RECEIVED BY" ^.-DATE' '", PERMIVNO. +.EH 13_24r(R riK3r .L_ R d .;_ - ,.,, ,A.,w., � G ] EH 14-28