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APPLICATION FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby made to the San Joaquin Focal 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 Addressr "?5 0 City Lot Size PM iJ(�((1' � Address Phone ,i_< ,1 11 Owner:s�.Name•` - f ty� (d. y �*7� (� c �.Y f y 2 .0 2 SJ�9 } Address / License No.� Phone Cbnhac_t TYPE OF-INELL PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r: - PUMP INSTALLATION C1 Sy REPAIR El 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 ❑ Inclustrial ❑ Open Bottom I LJ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack -„,�❑ Tracy Type of Casing Specifications {`i Public r Cl Other 71 Delta a Depth of Grout Seal Type of Grout ` I I irrigation _..Approx. Depth I I Eastern —Surface Seal.lnstalled by Repair Work Done ❑ Type of Pump H.P. �` State Work Done^ Well Destruction ❑ Well Diameter Sealing Material Itop,50'l-7— Depth 'ler Material IBelo 501 TYPE. OF SEPTIC WORK: NEW INSTALLATION I 1 EPAIR/ DDITION DESTRUCTION I k iNo septic system permitted if public sewer is ,-- - - a.,-- �j available within 200 feet./ Installation will serve: Residence ..v Commercial_r�Other 1 Number of living units: � Number o roo R Character of soil to a deptFirof 3 feet: _ '� r'�”`-� '-' ' Water table depth t✓' SEPTIC TANK ElType/Mfg Capacity No. CompartmentsS r PKG. TREATMENT PLT. ❑ # Method a1 Dispose r Distance to nearest: Well Foundation Property Line LEACHING LINE Lr- .No. fig Length of lines B ..� T notal length/size 7 �� Property Line FILTER BED ❑ Distance to nearest: Well Foundation _ SEEPAGE PITS N I _Depth T r Size Number f o ! SUMPS Ll }Distance to nearest: v Well -Foundations Property Line-15- DISPOSAL DISPOSAL PONDS ❑ r- w - w 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, 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 i 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." The applicant st call for all qwr inspections. Complete drawing on revelr7 9 7 Signed X Title: v F Date: 1t FOR DEPARTMENT USE ONLY j Application Accepted by Date Area 6 t or Grout inspection bate /' 1Final Inspection by �� ' Date` y i Additional Comments: f ❑ 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 AMOUNT DUE AMOUNT REMITTED CASH . RECEIVED BY DATE PERMIT'NO. INFO 1 + EH 13-24(REV. /H 5) V d EH 14-28.