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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA . Telephone (209) 466-6781 I 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1 Job Address City �� Lot Size PM Owner's Name - Vh /1't PAC r �/ - Phone ` Contractor ✓ v Me Address 3-I 60 6��f k j/ License No. � Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ k PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 171 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑ Manteca _ Dia- of Well Excavation Dia. of Well Casing Ci Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �.M Specifications F] Public ❑ Other n Delta Depth of Grout Seal * Type of Grout _ I 1 Irrigation --Approx. Depth I I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Donee Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') f f } TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is I available within 200 feet.) J •Installation will serve: Residence— Commercial—' Other y Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK X Type/11Afg L Capacity t'"V No. Compartments PKG. TREATMENT PLT. ❑ j� t J � Method of Disposal r Distance to nearest: WellFoundation ► Property.Line 4 "LEACHING LINE No. & Length of lines: Total length/size 147 Q FILTER BED ❑ Distance to nearest: 5 Well oundation Ute-7 +_ Property Line t '. ASEEPAGE PITSDepth< ~Size T "� Number SUMPS L�Distance to nearest: Well /5�7-)_d.Fo ndation l -a Property Line DISPOSAL PONDS ❑ l I hereby certify that I have prepared this application and that thee 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 i employ any person in manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: '! ertify 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 Californi .' k The applican ust for al r quired i s pl drawing on re so side. f Signed � Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date r 22 Area Pit or Grout Inspecti y Date /F}in�a�l I�spect n by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all co les to nvironmental Health Permit/Services 1601 E. Hazelto Ave., P. Box 2005, S ., CA Ol INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +_EH 13,24 PREY.IIA57 �l.'a llv �� • ��^e�-�D �] —JSb �� . EH 14-2a