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t 1 APPLfCATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heisby 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. Job Address ALg�I W, City / ' Lot Size s��Z PM Owner's Name/ Address r(g � f!'t liesd b Phone p Contractor "-Address &_,O& � License No.l.32a75— Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE_W€LL ,,,�,�,�_.. OTHER WELL PITS/SUMPS INTENDED USE ' TYPE OF WELL PROBLEM AREA E CONSTRUCTION SPECIFICATtos } _ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S'taiftcations 1 11 Public ,, , _ C1 Other n Delta +Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern j Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 - Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is - / available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: __/_ — Number of bedrooms Character of soil to a depth of 3 feet: Water table depth+ SEPTIC TANK R`Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 41 Method of Disposal v Distance to nearest: Well,o&212 Foundation_aP5 Property Line LEACHING LINE fdL No. &length of lines Total length/size FILTER BED ❑ Distance to nearest: Welles Foundation 15�or_ Property Line ��• ' SEEPAGE PITS 4 " Depth I! Size If-4 Number SUMPS ❑ Distance to nearest: Well /gWL Foundationv4:'1 Pr operty 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 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, 1 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-1611dwing:"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 applicantu call for all squired inspections. Comptbte drawing on reverse side. Signed XTitle.�k-ml Date: Z""y 4 ,2 FOWDEPARTMENT"USE ONLY nQ Iication Accepted by e 4 Date —1�� Area Pito Grout Inspection by Date , in0lnspection by Date 4 �/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 836-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E._Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO +AMOUNT DUE AMOUNT REMITTED` ASH RECEIVED BY DATE PERMIT*NO. aEH13.24(REV.1/N5) `t' bC t ' kl ^ 3't'.