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,f APPLICATION-FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1 1601 E. HAZE T ON AVE.,,STOCKTON, CA Telephone (209) 466.67$1 - PERMIT EXPIRES`l YEAR FROM'DATE 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 Regulations of the San Joaquin Local Health District. Job Address City C , 4 f t Lot Size PM Owner's Name�((Sa Q 2 Address 51f ;. r C/o Phone Contractft GC r 7 ' Address ip TYPE OF WELL/PUMP: License No, 'ZZtt Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANK , r. PUMP INSTALLATION El SYSTEM REPAIR C1 OTHER [7' SEWER LINES DISPOSAL FLD. PROP. LINE _. FOUNDATION _AGRICULTURE WELL OTHER_W. ELL f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -PITS/SUMP_S_ ❑ Industrial O Open Bottom ❑ Manteca, I t - Dia-of l/1]ell Eicavation-- �1 Dia. of Well Casing L1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing y .Q Public Specifications ED �.-�..W❑_Delta.,_,,,.� Depth_of-Grout Seal--- Type-of-Grout ❑ Irrigation - -—- j-a - -- �Approx. Dept,' EJ Eastern Surface Sea! Installed by Repair Work Done ED Type of Pump i, H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth -_� Filler Material (Below 50']_ TYPE OF SEPTlC WORK: NEW INSTALLATION �' REPAIR/ADDITION ❑ DESTRUCTION ❑ [No septic system permitted F p tted if public sewer is Installation will serve: 'Residence available within 200 feet.) .� 'Commercial Other x ,,, Number of-living units: Number f ec`r'oo sr' — Character of soil to a depth of 3 feet: 2 / Ih SEPTIC TANKype/Mf / Water table depth g 5 PKG. TREATMENT PLT. ❑ .. x-,� Capacity_r�G� No. Compartments p rtments / \� rL i Method of Disposal Distance to nearest: I Wellti�r Foundation -� f 7 1 f •,,: .� --9G -__P_ropert.Y_L-ine--��it�� r IT LEACHING LINE VK'No. / x, No. & L'ength of lines -� , ¢ "' l ' '"•' FILTER BED Tetallllength/size= XP { ❑ Distance to nearest J Well r + F ff _ Foundations;Property Line_3�-► _! SEEPAGE PITS C2"-Depth r x Size � `• r �'' N mber`..4 ��...� :� SUMPS ❑ Distance to nearest: Well . I `' " / \ # - _ Foundation, [ PropertylLine_7 DISPOSAL PONDS ❑ � . �. .-. �. I hereby certify that! have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,nes, 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring oPsub contracrmit is tng sgnaltu�e certifies the following:"t certify that in the performance of the Werk for which this permit is'issueal I shall C to tion laws of California." f. Ploy Persons subject to workman's compensa- Z The applicant m call for all quir inspections. Complete drawing on reverse side. I t Signed X i Title: �. Date:' FOR, EPARTMENT USE ONLY t i # Application Accepted by Date j3 Area r Grout Inspection by. f" r' (/ Date final Inspection by Additional Comments: ! r Date" ❑ Stk 466-6781 �❑ Lodi 369-3621 ❑ - f Manteca 823-7104 El Tracy 835-6385 ' Applicant.- Return all COIEnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 9 INFO CASH RECEIVED BY.. DATE PERMIT'NO. -+ 13-24(REV.t/R5) EH 14-2 ©,