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APPLICATION FOR PERMIT j " 1 SAN JOAQUIN LOCALHEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA ! Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED .. v, �(Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th'e 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 1ggghe Ryles and Regulations of the San Joaquin Local Health District. ;_ a l l G r' CityN Lot Size PM Job Address _T �/✓/�// 49T Address Owner's Name � � i 9 � Contractor �` �r�/�4—Address _?,?o 1 / dN Licse NJ Phone -TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ y PUMP INSTALLATION 1:1SYSTEM REPAIR ❑ I� OTHER ❑ 16ISTANCE TO NEAREST: SEPTIC TANK .-- SEWER LINES ', DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLAI -' ,PITS/SUMPS r;. t .r.,.INTENDE-D.USE TY-PE OF•�WE1�L- �PROBtEM AREA'S--CON,STRUCTION-SPECIFI'CATIONS�—^- +❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I1p Dia. of Well Casing ❑ Domestic/Private ❑Gravel Pack El Tracy Type of Casing iP Specifications El Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout• r 1 ❑ Irrigation r_ Approx. Depth ❑ Eastern Surface Seal Installed by �p�p i Repair Work Done El Type of Pump H.P. State Work:Done >y r Well Destruction ❑ Well!#Diameter ') Sealing Material (top 50 dG R �Depth - - Filler Material (Below 50'► t . 11 TYPE OF SEPTIC WORK:-NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is availabyle within 200 feet.) . i IIAII Installation will serve: ..Residence Commercial_ Other 1yII I �J 'of'bedro . •w as�s wnx'� r k T Number of living units: '1 Nurtiberoms Character of soil to a depth of 3 feet: -# � -� ` Water table depth SEPTIC TANK ' Type/Mfg (/ Capacity,` No': Compartments �S'4� R� k" "'r; , 2 � . : PKG.TREATMENT PLT: ❑- {. ► �' f Method of Disposal i �� ' Distance to nearest: Well_100 Foundations Prope�py Line �®� "f" - : LEACHING LINE ! No 40 &`Lengthiof lines f77 Total length/size ' i FILTER BED ❑ Distance to nearest: —Well i.-J Foundation Propehty Line r 1 k +J- ) SEEPAGE PITS 1J Depth � - Size -- N mber 4 SUMPS ❑ Distance to nearest:' Foundation Property Line ' DISPOSAL PONDS ❑ V y 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, andi.,!_ 1 rules and regulations of the San,Joaquin Local Health District. 1�`• pp I Home owner or licensed agent's-signature certifies'Itlie following: .I jcertify that in.the performance of the work for which this permit is issued, I shall notj' - 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-i tion laws of rnia." 1 s The appli nt mut II, r II req ire i ctions- Complete drawing on rave side. Signed � � a7itle: �_�� /!'l Date: -« J FOR DEPARTMENT USE ONLY q Ilp Area Applicatio ccepted by Date ' i 0 Pit or Grout Inspection byy� Date „Final Inspection•b Additional Comm6nts: x ' 1 •❑ Stk 466-6781 ElLodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 _ s Applicant.- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P:, Box�I.009, Stk.,`CA 95201 •FEE, AMOUNT DUE AMOUNT REMITTED` CK CASH RECEIVED BY 1P DATE PERMIT'NOi -• INFO - „ t +fH13241REV.t/s5) Z, 60' EH 14-26 ��