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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) I 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 welUpump and the Rules and Regulations of the San Joaquin Vocal Health District. r Job Address � ) City Lot Size/ 01113 4m. PM Owner's Name Address Phone Contractor ..a Address 45� 717 T License No. Phone_ I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © TRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR E OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FI-D. PROP. LINE FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack acy Type of Casing Specifications f'1 Public I-1 Other ❑ Delta Depth of Grout Seal Type of Grow_ _ I I I Irrigation _..Ap Depth I I'Eastern Surface Seal Installed by Repair Work Done ❑ T of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is yy available within 200 feet.) Installation will serve: Residence L Commercial Other Number of living units: _/ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK i r Type/Mfg &44 Capacity `L 4O No. Compartments ' PKG. TREATMENT PLT. C] ?- r Method of Disposal } Distanceto nearest: Well a D Foundation t r Property Line I� `L 4 LEACHING LINE No. & Length of lines �� ? JytpLl Total length/size G FILTER BED ❑ Distance to nearest: WellFoundation J19 Property Line SEEPAGE PITS I i Depth Size . .r 1[4 Number SUMPS l Distance to nearest: Well1f� Foundation Property Line DISPOSAL PONDS ❑ i 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,pan 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 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must c II for all required inspections. Complete drawing on reverse side. Signed X Title: -- Date: (I FOR DEPAR MENT USE ONLY " Applii tion Accepted by ,.to Area �J s /► fit or Gout lhSpection by Date Final Inspection b ? — T7:fel-Date T- i a 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 0 Tracy 835-6385 _ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,.Stk., CA-95201 1FEEO AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY !/DATE PERMIT NO. +.EH 13.24(REV. EH 14-26