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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA w Telephone {209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is.hetehy made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is a 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. [60 Job Address 1 C! �` !v � y City �Y�� Lot Size ft J� a- -t=om' PM f ~ r Owner's Name Address! �a � Phone ` it Contracto r 1 !eti Address �� 3r7�7 ^z�c �� License No..3-2-2 � Phone .TYPE OF WELL/PUMP: - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLD. PROP, LINE FOUNDATION AGRICULTURE,WELL OTHER WELL PITS/SUMPS 01 O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -11 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public CI Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I ),Eastern Surface Seal Installed by - Ak Repair Work Done ❑ Type of Pump H.P.- State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 t]epth Filler Material (Below 50'1 t i TYPE OF SEPTIC WORK: NEW INSTALLATION ArREPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_i"l Commercial— Other L. - _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: A�s..� Water table depth..... f ' t SEPTIC TANK F 9�"Typ�//Mfg �i � c�z� Capacity No:�Compartments PKG. TREATMENT PLT. ❑ # FMethod of Disposal f"* Distance to nearest: Well /�a Foundation /P Property Line Jnc 1 LEACHING LINE =No-&Length of lines Q Total length/size a FILTER BED ❑ Distance-to nearest:<,r:Wel1.--/Ce Foundation__.._/P 4& Property Line , _ t SEEPAGE PITS 1 Depth Size'i 3 f Number t SUMPS Ll' Distance to nearest: Well J�G� Foundation /_,_. � Property Line w DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and the 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 of California." The applicant must call for all require " spections. Complete drawing on reverse side. Signed X 64� Title: Date: - 2 S X 7 FOR DEPARTME T U5E ONLY Q Cyf Application Accepted by e uL._ Date 4 [ ?IV) _ Area OU7 Pit or Grout Inspection by Date Final Inspection by Date «. Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623 1 ❑ Tracy 835.6385 (�! � Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ( DATE PERMIT'NO. f'/moi + EH 13-241REV.1 51 �� rUf:� - I ��[ (� Iµ�{ EH 14-2e �V�� i [ C] rJ l