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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YlEAR'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 I made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. t / "C) tot Size �.Yti _,- PM Joh Address City f n1 Ohre �/ "'f Phone � +�(� awner's'Name Address r \�Contractor Address License No. Phone_ p TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS CIP INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t �.❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ©'Domestk Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications }� n Public � k �❑ Other � Ll Delta <" Depth of,Grout`Seat--f_ — Type of Grout—.— I rout I kirrigation .y A' _•App`ox'. Depth t I Eastocn-^ Surface Seal Installed by Repair Work Done i El Type of Pmp,z l H.P. State Work Done ) j r �. Sealing p 1! . Well Destruction ❑'� Well Diameter- g Material [to 50') A Depth r T't ` Filler Material I Below 50'1 w i. TYPE OF SEPTIC WORK: NEW,INSTALLATION PC REPAIR_/ADDITION"(e], DESTRUCTION I 1 INo septic system permitted if public sewer is [ ` �Qi _ � i 1� " , available withA200 feet.) �. r Installation will serve: Residence `'NCofninercial _ e- s i Number of.living units: 1Number of edraoms -57 y 1 13 Character.of soil to a depth of 3 feeii ' Water table depth SEPTIC TANK ❑"`Type/Mfg Capacity'e;ZU-0 No. Compartments PKG. TREATMENT PLT. ❑ g 4! l Method o If sposfil Distance.to nearest: Well�_--,JFoundation Property Line LEACHING LINE $--No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest : Well _ Foundations Property Line I ► 4 1'r�-• k SEEPAGE PITS 1 ) Depth 0 LD Siie f rumber SUMPS Distance�to neare§t: Well }� AFoundation�� Property Line I' -DISPOSAL PONDS © } i hereby certify that I have prepared this application and that th'e work will be done in accordance with San Joaquin Icounty ordinances, state laws and f rules and regulations of the San Joaquin Local Health Disrtrict.'i n� Home owner or licensed agent's signature certifies the follewin :"I certify that theperformance of the work for=which this permit is issued]I shall not employ any person in such manner as to becomd subject to workman's compensdtion laws of California.'-Contractor's hiring-or sub-contracting signature certifies the following: "I certify that in the performance of the work for which thislpermitis issued, I_sh8I3:eriiploy..persons subiect to workman's compensa- tion laws of California." The appli t must call r all req�ujiredin_spections. Complete drawing on reverse'sidew• Signed k �� *��* ' Title: Date: r fi DEPARTMENTRUSE ONLY I Application Accepted by f Date Area or Grout Inspection,6y 1 Final Inspection In Ae Date I y. . Additional Comments:. 1 �; ❑ Stk 466-6781 ❑ Lodi 369-3621 10 Manteca 823-7104 ❑ Tracy 835-6385 . �` Y ! Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMDUNT RdMITTED CK REC IVSD BY DATE PERMIT'NO. //�► ,�/�r CASH r EH 13-24{REV.r/n 51 7 ` OD ' EH 14-26 i _ !-