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fix~ 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 r 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 f Local Health District. j� f 1 [Contractorts? ob Address " `' t + wa City f /Ddb - Lot Size PM Owner's Name Address Phone c6h G 0 Address ��r f '�� License No.4. Z�I�� Phone 4 3� TYPE OF WELL/PUMP: _ NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP-INSTALLATION ❑ SYSTEM REPAIR El OTHER 11 DISTANCE TO NEAREST:,SEPTIC TANK s .SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL Or, PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of.Well Casing ❑ Domestic/Private E1Gravel Pack ❑ Tracy Type of Casing :Specifications i'1 Public M Other Cl Delta Depth of Grout Seal Type of Grout t.. I i Irrigation Approx. Depth l I Eastern Surface Seal;lnstatled by - a Repair Work Done -❑ Type of Pump H.P. ~ State Work Done +, Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filier Material (Below 501 \�1� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is (' available within 200 feet.) `J A % fi nn Installation will serve: Residence Commercial— Other +. Number of living units: Number of bedrooms £ i Water table depth = Character of soil to a depth f 3 teat: r� SEPTIC TANK TypelMfgt Capacity Z d No. Compartments PKG, TREATMENT PLT. ❑ 7 0 � .» Method of Di Distance to nearest: Well Foundation / Property Line _. LEACHING LINE No. & Length of lines notal length/size A FILTER BED ❑ Distance to nearest: Well �� Foundation� Property Line �0 SEEPAGE PITS I Depth It7 r Size _ Number SUMPS �istance to nearest: Well WIP, 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. `_ I 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 manner 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for II required i spections. Complete drawing o averse side. %r Signed K Title: Date: [/ a I .FOR DEPARTMENT.USE ONLY - " l (� Application Accepted by Data r- Area q p. Pit or Grout Inspection by Dto al Inspecti by Date Additional Comments: ce s t Stk 466-6781 11 Lodi 369-3621 ❑ Manteca 8 ,\ V- 23-7104 ❑ Tracy 835 6385 (_ , Zia Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. BoxflM,Stk., CA 95201 FEE EMITTED CK RECEIVED BY DATE PERMIT'NO. AMOUNT DUE AMOUNT R INFO CASH ♦ EH 13-24(REV.I/x 5) EH t4-2e —