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Y - 1 APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 ands 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. r Job Address 1 l 7 k /L!1 r /JJ��/ a r City Lot Size PM Owner's Name Address�f f✓!/� �(.Y-f , , �d PhoneY77 73S -• Contractor's Name License No. a r r� Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑', DESTRUCTION ❑ s PUMP INSTALLATION ❑ ; ;SYSTEM REPAIR ❑ 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 f € ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing. ❑ Domestic/Private 11 Gravel PackTracy Type of Casing Specifications 4 ❑ Public ❑ Other ErDelta Depth of Grout Seal Type of Grout �^ ❑ Irrigation ---Approx. Depth ❑ Eastern Surfice Seal Inst:ailed by 6 f Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Materialltop50')4 Depth Filler Material=lBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLgT10NREPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is Z y/ available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of oms Character of soil to a depth of 3,feet: IV. _� �� Water table depth--... SEPTIC TANK � Type/Mfg Capacity 71) No. Compartments x _ PKG. TREATMENT PLT. ❑ f- I I Method of� ' Disposal _Distance to nearest: Well "f" Foundation/4L= Property Line ! _ 4 LEACHING LINE Y No. & Lengih'of lines - `Total length/size— f . 1 FILTER BLED i ED Distance to nearest:"""W614 r 'Foundationt / 11L property tine r � SEEPAGE PITS Depth ^?�..., Size J o7► Number ' SUMPS _ '❑`" Distance to nearest:' Well illto r�" Foundation le) rt' Property Line DISPOSAL PONDS ❑ `~ 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. C ,v,— 40.1 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 a employ any person in such manner_as.to become subject to workman's compensation laws of California."Contractors,hiring or sub-contracting signature f 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.' 1 5 The applicant r%pt call for all quir spec' s: Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY ' Application Accepted by Date Area Pi r Grout Inspection by 7 Date `� Final Inspection by 5 3 Additional Comments: ' i ❑ Stk 466-6781 ❑ Lodi 36-3621 El Manteca 823-7104-- ❑'Tracq'=835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazatton Ave., P.Q. Box.2009, Stk., CA 95201 i � s CK INFO AMOUNT DUE (AMOUNT REMITTED CASH RECEIVED BY DATE, PERMIT'NO.' +EN 3,24(REV.10153) EN 1126