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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 1 YEAR FROM DATE ISSUED (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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. � Job Address 6?, �� Cit Lot Size 7 PM Owner's Nam Address � t' / r__ _ Phone f' ' /—�./�/��1z 7�7 ` License No. -ZZ-Z Phone Contract Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fes' ❑ Industrial. ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing r Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal,7 Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal installed-by Repair Work Done ❑ Type of Pump H.P. State�Work Done Well Deitiuction ❑ Well Diameter Sealing Material (top 501 ` Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Irp REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is " available,.withln.200 feet.) (� Installation will serve: Residence Commercial_ Other X., Number of living units: Number of r cros `71A ` Characterof soil-to a depth of 3.:feet: -... - Water table depth SEPTIC TANK Type/Mfg%, Capacity � �, o.-Compartments PKG. TREATMENT PLT. ❑ T ` 1 Method of Disposal Distance to nearest: Well ZP C Foundation Zb ...•Property Line . LEACHING LINE No. & Length of lines .Q _ F J _ Total length/size f� FILTER BED ❑ Distance to nearest: Well 11�90 Foundation 3Property Line SEEPAGE PITS Depth Size Nu Ver SUMPS ❑ Distance to nearest: Well /,00 -/ Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 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 no employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signatuI 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-liws of California." The applicant ust call fo I req 'red inspections. Complete drawing on reverse si e. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 1 Area Pit r Grout Inspection by7 r Date al Inspection by DateCi Additional Comments: 4?' -7/` ❑ 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 FEE t INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. i i.EH13-24(REV.1/a5) EH 11-2t1