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APPLICATVON`FOR PERMIT SAN .DOAQU111i LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I (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. ' f�8�`�'�,t s'f)n% S 1 - 2—Z3 S fV^ a Z City �� Pf: _Lot Size PM Job Address v f Phone Owner's Name Address i 1 �i ? 50 Wticense No.LC-y 6a 3 Phone Contractor TYPE OF WELL/ LIMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 6 A PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES --�— DISPOSAL FLD. PROP. LINE ' 01v FOUNDATION AGRICULTURE WELL '/ OTHER WELL PITSISUMPS ff I a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,mss F ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well U60ation Dia. of Well Casing L1 Domestic/Private ❑ Gravel Pack C1Tracy Type of Casing specifications I"1 Public ❑ Other e- � ': r1_Delta- i Depth of'.Grout.S;al Type of Grout 11 Irrigation —..Apprax Depth ['I Eastern Surface Seal Installed by Repair Work Done—.El-•Type-of-Pump W ._7_-..— _.H.P- - —t - - _ .State Work-.Done Well Destruction Well Diameter + Sealing Material (top 50'1 1 Depth Filler Material (Below 50') Zt TYPE OF SEPTIC WORK: NEW INSTALLATION [ 1 REPAIR/ADDITION I DESTRUCTION I 1 Mo septic system permitted if public sewer is F available within 200 feet.) Installation will serve: Residence— Commercial_ Other f w L Number of living units: Number of bedrooms O Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 171Type/Mfg Capacity ' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line f t t LEACHING LINE ❑ No. & Length of lines Total length/size L FILTER BED ❑ Distance to nearest: Weilg Foundation - Property Line SEEPAGE PITS 11 Depth f Size _ Number r SUMPS LZ Distance to nearest: Well Foundation ' Property Line DISPOSAL PONDS ❑ ► N I hereby certify that I have prepared this application and that the work will be,done in accoidante with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. [� edI shall not Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issu , employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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." i The applicant ust tali for all relVired inspections. Complete drawing on reverse side. L4—"e l I 4 -ne �_ O-71� hoc 4 Date: "� 6 ` + Title: Signed X i FOR DEPARTMENT USE ONLY Application Accepted by Date Area Date Final Inspection by 4 la Dr u +� Da ' Pit or Grout Inspection by ive �J y Additional Comments: `�$ ~ �y_� ❑ Stk 466-6781 ❑ Lodi 369-3621 -,:0 Manteca 623-7104 ❑ Tracy 835-6385 1 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 EH 13-24(REV,i/x51 EH 14-28 - - --