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i } APPLICATION FOR PERMIT Vol SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 1J Telephone (209) 466-6781 PERMIT EXPIRES '/'YEAR FROM DATE ISSUED q (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. J g, art-YO i I�4aC�1�C PM Job Address71 City Lot Size Owner's Name4_[YY!'�..'.e l Address N� I f� l/3c l y. Phone ' Contracto n 1 Address � � TYPE OF ftELLIPUMPW WELL WELL RI PLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES 100 / DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS7-0 EJ Industrial LI Open Bottom Cl Manteca Dia. of Well Excavatio /Z Dia. of Well Casing W Domestic/Private Gravel Pack ❑ Tracy Type of Casing !/ ` Specifications r FI Public F1 Other f7 Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth LI Eastern Surface Seal Installed by -- - Repair Work Done ❑ Type of Pump H,P. State Work.Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material /Below 50 — J TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other r Number of living units: Number of bedrooms p Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal l Distance to nearest; Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line_ SEEPAGE PITS I I Depth Size Number ' SUMPS Ll 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 Hearth District. Q� 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, I shall not employ any person in such mariner 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,1 shall employ persons subject to workman's compensa- tion laws of California." I. ' The applicant must call for all'required inspections. Complete drawing on reverse side. i Signed X�1�[i ��fl� .C.td,{].� __ Title: d2tt�-I74_y► _ _ Date: G I: FOR,DEPARTMENT USE ONLY �--� I Application Accepted by _ z Date Area Pit or Grout Inspection by Date Final Inspection by�� f _ Date ✓2'. , ``j � II Additional Comments: . ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 k Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH +.EH 13-24 IAEV.v n sl ' t4 1'I -ZzLi s EH 14-28