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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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' f the San Joaquin Local Health District. Job Address _ 12Nk�T �� 13 oe G City G Lot Size PM Owner's Name Address T� e - Phone Contractorj-/)_,�-yL.Gr5 Address License.No. cr Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L1DESTRUCTION .❑ _iPUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ q. DISTANCE-TO NEAREST--SEPTIC TANK SEWER LINES += DISPOSAL FLD. PROP- LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL y PROBLEM AREA CONSTRUCTION SPECIFICATIONS JII p ❑ Industrial ❑ Open Bottom d7manteca` Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack . �, 0-,,Tracy Type of Casing Specifications11 fl Public fl Other Ci Delfa Depth of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth 1.1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. # State Work Done _ �M Well Destruction ❑ Well Diameter 3Y F � Sealing Material (top 501 �. Depth Filler Material (Below 501 — �} TYPE OF SEPTIC WORK: . NEW INSTALLATION I1 iREPAM/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will'serve:: Relsidence ,}Comrnercial'_ Other Number of living units: ._.[-- Number of bedrooms___,___.._-.. . G/ Character of soil to a depth'of 3 feet:_44- � _`>6" -~ . • Water table depth �I 1-- �M SEPTIC'TANK EJ _p t: _, ' -_ Capacity No. Compartments PKG. TREATMENT PLT. ❑ 4 ;.` F ' j Method of Disposal �� y F Distance to nearest: Well L -- ,Foundation Proper#y.Line d „_LEACHING LINE . No: & Lengttft o"f lines " Total length/size �M FILTER BED E] Distance to,ne est=` Well;,]�,F�Foundation y5Property Line SEEPAGE PITS i I Depth r` Size Number ��- SUMPS ❑ Distance to nearest: Well' Foundation Property 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 permitisissued, I shall not employ-any person in such manner as to became subjectlto 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 musts call for all required inspections. Complete drawing on reverse side. Signed X��fJir_ :J __ Title: Date: —� 100W/ FDR DEPARTMENT USE ONLY 17J i� Applicationr ��Accepted by . Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk _466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE -INFO' ^^AMOUNT-DUEn .AMOUNT-REMITTED `CK C SH -RECEIVED,BY DATE"" PEF(19161Z.' � �. +EH 13-24 IREV.r i n 5� T r---•, _ .. ,,,,. T -�--„ -fl— »� ..- -,« !} 1,....„r.�«ka.,M-. - --^�f"•. — .. i EH 14-26