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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. y (� Job Address +� LA s 0 - -`.' � � � City Lot Size AS4,K (.6 6 PM ,a a-3 a nl [� u Owner's Name Address Phone5�� Contractor .Xm�}4?tArC.MA s I G�e7C `11.ta, n License No.-371>34 1_Phone ®;L3677_1 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I`l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout --- I I Irrigation —.Approx. Depth .( 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 1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence K Commercial_ Other Number of living units _L__ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity a�0 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well _11,00 Foundation 30:L Property Line D} LEACHING LINE 11r No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well =0)A2L7— Foundation 10() Property Line SEEPAGE PITS I I Depth Size Number SUMPS CI 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 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 Dioat that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- tion laws of aii rnia." The applica st call fequuireed inspections. Complete drawing on (averse side. �A�> �,,rb Signed X Title: l,. 4 .- Date: IZ� Fl RTMENT USE ONLY Application Accepted by ,tilfflo� ,. � i0ate a Pit or Grout Inspection by Date Final Inspection by Date -,V-F7 i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 &...,...,,Applicant - Return all copies.to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 9520"FEE ��i INFO AMOUNT DUE AMOUNT REMITTED ASH RECrrrE��I��-VED BY DATE /1PEERMIT"N0. + EH 13-24(AM 1/H51 © Ur,) �drUL� � EH 14-2a l! O ` + p 1