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I• 41. APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. FIAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ry 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin I Local Health District. Job Address City Lot Size. PM Sem Owner's Name � � � Address Phone Contractor Address SBD Ci¢�� License No. Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT..❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER F-1 " DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ISPOSAL FLD. PROP. LINE ! FOUNDATION AGRICULTUfl OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROB EA CONSTRUCTION SPECIFICATIONS— ----------7 ❑ Industrial LJ Open Bottom Manteca Dia. of Well Excavation Dia: of WellCasing i ' ❑ Domestic/Private ❑ Gr ack ❑ Tracy Type of Casing Specifications ❑ Public Other ❑ Delta Depth of Grout Seal Type!!of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by R ork Done C] Type of Pump H.P. State Work Done v- Well Destruction ❑ Well Diameter I Sealing Material (top 501 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION D ! REPAIR/ADDITION Vf DESTRUCTION ❑ (No septic system permitted:if public sewer is `T available within 200 feet.) i Installation will serve: Residence— Commercial_ Other I Number of living units: Number of bedrooms Character of soil to-a depth of 3 feet: �� ''. ` Water table depth SEPTIC TANK ❑ Type/Mfg J F Capacity No. Compartments 1 3 (-PkG: TREATMENT-PET'❑ PMethod of Disposal Q Distance to nearest ,,,,,,,,,, ,- Well—_Foundation ropey rty line _ f (LEACHING-ONENo:&LVngth of lines 2-. �T �r Total length/size l76 FILTER BED ❑ Distance to,Aarest:: Well. Foundation 7a Property Line ® 49 s 'SEEPAGE PITS 'Depth 2 �s -Size tit 6 112-VI'/f _ Number 2 1 ) S}UMPS ,G _❑ .Distance ta_gearest:, Well ! Foundation /7-40 Property Line,, # DISPOSAL PONDS ❑ } r 1, ereby certify that I have prepared this applicatiob and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ules_and_regulations.oft3he..SanJoaquin-Local-Health District. .� .ameyownerior_icensed agent's signature certifies-.tfie following: "I certify that in the performance of the work for which this permit is issued, I shall not ey employ any person in such manner as to become subject to workman's compensation laws'of California."Contractor's hiring or sub-contracting signature �cr,If'es the-following-='decertify-that-in-the,performance of the work for which this permit is issued, I shall employ persons subject to wor BA's compensa- tion laws of California." t. j The.applicant must call fo aqu'�ed in ction mplete drawing on reverse side. Signed ! Title: Date: lfr FOR DEPARTMENT USE QNLY I 1 Y µApplication Accepted by Date Area Q Pit or Grout Inspectio 'Date " Final Inspection by Date --.--AdditionaE=Commentsr - - - - - - - -- -- - - ❑ Stk 466-6781 ❑ Lodi 369-3621 T ❑ Manteca 823-7104 1 ❑ Tracy )1;(!5-63854 Applicant- Return all copies to: Environmental.Health Permit/Services 1601 E. Hazelton Ave.;P.O. Box 2009, Stk., CA 95201 "d 1, r , FEE CK INFO AMOUNT DUE AMOUNT REMITTED +CASH RECEIVED BY DATE PERMIT NO. EH 1324{REV.1/e 5) I J u EH 1425 71) t COC^1 /S/ �/ i