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9 APPLICATION FOR. PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209).466-67$1' PERMIT EXPIRES,1 YEAR FROM yDATE ISSUED (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,eeguiations of the San Jc0quin Local Health District. , �Q 4f'.�� `'c� 1 1 e� � y � ity Lot Size� J� - PM x � Job Address . . Owner's Name ` ,YCddress m •”' xhone Contractor's Name 4�' -t nse No. Phone `o X TYpe,Q 'YVELL/PUNEW WELL ❑ WELL REPLAGEMJENT ❑ DESTRUCTION ❑ r.G. - 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 _- .� ❑ Industrial ElOpen-Bottom-�-' -E• -Manteca---- - Dia. of*Well Excavation ----- --- - Dia. of Well Casing ❑ Domestic/}Prrivate,.,; ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Uriglation { ❑ Other_�4pp ox.~ ❑ Delta Depth of Grout Seal _ Type of Gr�S,ut � . t`*'f^� � I DeWh El Eastern - S,OOace Seal-Installed by `+ Repair Work Done./.El Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 a, Depth Filler Material (Below 501 _ X TYPE OF SEPTIC WORK: NEW INSTALLATION'[] REPAIR/ADDITION ❑ DESTRUCTI WQ�f(No septic system permitted if public sewer is (� � 'A-A available within 200.,feet.) —Installation will serve: Residence_ Commercial_ Other t { N tuber of living nits: Number of bedrooms t } ..:,y Character of soil to a depth of 3 feet: " "'^ � ""`�" _ Water table dep h 5 t / • ter, ' tI SEPTIC TANK S ❑ Type/Mfg,;' i Capacity 41 No. Compartments �41- V 4 PKG. TREATMENT PLT. El � _ _ »-- ..f Method of Diposal i Distance*td ne,@ Well y i Foundation a P Wp-erty tine LEACHING LINE No: & Length of lines '- Total length/size FILTER BED El Distance to nearest: Well Foundation f" """"� Property Line • _ SEEPAGE PITS SUMPS `w� tEl ElD stance to nearest: Well Foundation___1 perty L r p r i Number "'"" � r rad+Pro Line��—"" -► :,,as� DISPOSAL PONDS, C1 I hereby certify that I have prepared this application and that the workI will be done in accordance with San J aquin 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 whlc4 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 hirir)`g 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 persons4ubiect to workman's compensa- tion laws of California." - »- .-.-- The app' for all r qui spec; ns. Complete drawing on reverse side. Signed X� itle: Date: FOR D T NT USE ONLY Application Accepted by Date Ve Pit or Grout Inspection by Date ! Final Inspecti to Date f Additional Comments: — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.;,CA 95201 t FEE p { INFO. AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. - 5 +EH1324(REV.10/631 fEH 14.26 _, � � � -