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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, _CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED n (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. ? i Job Address 7 Cityglpjg�� Lot Size PM r Owner's Name �o /iG<s w✓5 Address Phone _�r2s�_��.— '- Contractor Address License No. Phone TYPE OF WELT;/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION F1SYSTEM REPAIR El OTHER ❑ DISTANCE TO!NEAREST: SEPTIC TANK SEWER,LINES _-_- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULJi7RE"WELU' " OTHER WELL PITSISUMPS .INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial } CI Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public i Cl Other Cl Delta Depth of Grout Seal Type of Grout ---- I i Irrigation � _..Approx.:-Depth E I Eastern Surface'S;eul;lnstalled by Repair Work Done ❑ Type of Pump H.P. 5tate,Work Dane i Well Destruction ❑ Well Diameter Sealing Material'(top 501 Depth Filler Material (Below 501 ` TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) -Installation will.serve:, Residence ✓ Commercial-Other - - -- - - � ,• w - Number of living units: ? Number of bedrooms # ,' Character of soil to a depth of 3 feet: �tl 4� l Water table depth ^� SEPTIC TANK ❑ TypelMfg �f -� L� _ CapacityQ_— No. Compartments ), PKG. TREATM NT PLT. ❑ �'�T- Method of Disposal 1I Distance to nearest: Well Foundation Property Line -_� S` i LEACHING LINE 'f" No. & Length of lin>is.. /y — '.,Notal length/size �- d+�—. FILTER BED r ❑ Distance to nears tY• Well Foundaiiorrz� Property'Line _ —fir SEEPAGE PITS] C 1 iDepth Size Number".,- , } , SUMPS L1%."'Diktan-dtd-hearest: Well Foundafiori.�_. Property Line DISPOSAL PODS C7t".'`. 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 San Joaquin Local Health District. ( Home owner orilicensed 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 per on•in-seieh•manner-as,to-become subject'1o`woikman's compensation laws of California." Contractor's hiring or sub-'dontracting signature certifies the fol11wing: "1 certify that in the performance of the work for.which this permit is issued,I shall employ persons subject to workman's compensa t tion laws of California." ? The applicant must call or all quired 'nspections. Complete drawing on reverse rse side. 4 Signed X. '� . `� Title: _ Date: tom/ FOR DEPARTMENT USE ONLY Application Accepted by $ ___ I Date ok z Areae,-. Pit or Grout Inspection by Date Final inspection by r Da% Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82341104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 iE. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 CK FEE AMDUIVT_bUE ,. - AM4UN7 REMITTED.- .meg �H .F. .RECEIVED.-BY: --DATE-- --PERMIVNO. :_ ~ +.EH 13-24[REV.1/a.51 EH 14-26 -0 / �$-l T59 '-ba