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Y' r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone Q091 466-6781 5. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NOS (Complete in Triplicate) Nq L� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of install the work herein described. This ap lication 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. �� Y City Lot Size 1219 Y/t a PM Job Address X ,J ��I !/ 3 2 Phone Owner's Name Id I r1s Address Contractor Address License No. Phone TYPE OF WELL/PUMP: :If NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r l. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` ❑ Industrial ^ ❑ open Bottom- ❑ Manteca Dia. of Well Excavation Dia. of Well Casing LJ Domestic/Private ❑ (Gravel Pack ❑ Tracy Type of Casing Specifications I fl Public F1 `Other Ci Delta Depth of Grout Seal Type of Grout r I I irrigation -Approx. Depth •.1 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ W31 Diameter Sealing Material (top 50') li - Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION 1 1 DESTRUCTION No septic system permitted if public sewer is Installation will _ serve: Res!L(III available within 200 feet.} r e, nce Commercial Other Ql�)' Number of living units: Number of bedrooms rr` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ ype/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal pDistance to nearest: Well Foundation Property Line LEACHING LINE ❑ o. & Length of lines Total length/size FILTER BED ❑ NDistance to nearest: Well Foundation Property Line SEEPAGE PITS I I I 'Depth Size Number SUMPS 0 .Distance to nearest: Well 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, and rules and regulations of the Sian 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, t shall employ persons subject to workman's compensa- tion laws of California." r _The applicant must call for allhhhhhh',required inspections. Complete drawing on rev /NS\Signed X ih - _ Title: .►.� Date: T � yJ CJ FO DEPARTMENT USE ONLY Application Accepted by Date " " Area Pit or Grout Inspection by .I Date Final Inspection by Date Additional Comments: 0 d7'Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 835-6385 Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E_ Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEINFO NT DUE AMOUNT REMITTED D RECEIVED BY DATE PERMIT NO. 1 +. -5. yoEH 13-24(REV.I R 51 L V� EH t4-29 I�i -