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APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 of the San Joaquin Local Health District. QQ � Job Addressa J&2_4� Cit Y Lot Size,95-6f Z LA t 6 PM Owner's NamellJlht/`/7. t1M�Address 4 1�� - � � � Phone g — �a� Contract ` ! r �X= ��/X1�-i X ?92_2(0 Phone 9` Y�0 f Address Q0 License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL fl_D. PROP. LINE FOUNDATION /AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE ` - -TYPE OF—W-ELL.PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrialell ❑ Open Bottom ❑ Manteca Dia. of Well Excavatiori Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public "0 Other - r1 Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation _Approx. Depth i I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I i DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet-) Installation will serve: Residence Commercial— Other Number of living units: Number of rooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK V?o"Type/Mfg Jr Zr CdoacityNo. Compartments PKG. TREATMENT PLT. ❑ � 1 Method of Disposal Ch Distance to nearest: Well� Foundation in Property Linec2,s LEACHING LINE 91"'No. & Length of lines Total length/size I Oslo FILTER BED 11 Distance to nearest: Well100 Foundation Foundation _property Line SEEPAGE PITS I!!---Depth C96 Size Number SUMPS L'1 Distance to nearest: Well /SQ Foundation .4(L 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 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,f shall employ persons subject to workman's compensa- tion laws of California." The applican us t call fo II r wired inspections. Complete drawing on reverse Ida. ' 1 Q Signed X Title: �.r. Date: lir O FOR DEPARTMENT USE ONLY �� / 7 Ap lication Accepted by c7 Date//� /�/ -!� Area Pit r Grout Inspection by Date / Final inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 95.201 FEE INFO �AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY /DATE PERMIT'NO. + EH 13-24 IREV.1/a 5) EH 14-2e