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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL:`HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON,,CA i Telephone 1209) 466-6781 PERMIT EXPIRES 7'YEAR FROM DATE ISSUED! Ilp ,_ v ' (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 Ryles and Regulations of the San Joaquin Local Health District. Job Address4Cih'Q'x Lot •' Size PM Laws. Owner's Name Address y - •�,i.-K.JUC 'l� Phone'^^ _ Contractor Address License No. k 3 Phoney-66.`_ 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 E w FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � INTENDED USE TYPE OF WELL :PROBLEM AREA CONSTRUCTION SPECIFICATIONS l,r ❑ Industrial ❑ Open Bottom ❑ Manteca '�� Dia. of Well Excavation Dia. of Well Casing '< lmestic/Private ❑ Gravel Pack ❑ Tracy Type df Casing Specifications 17 Public ❑ Other 'I] Delta _..%. Depth of Grout Seal Type of Grout ON t❑ Irrigation /_Approx. Dept aID stern i Surface Seal Installed by y Repair Work Done i_ Type of Pump H.P. State Work Done C� y j, Well Destruction: ❑ Well Diameter 161 Sealing Material {top 50') !` Depth - Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 'DESTRUCTION ❑ (No septic system permitted if public sewer is _.`T41 `C_ available within 200 feet.) ` Installation will serve:;zResidence� Commercial"— Other i Number of..living units: -Number-of bedrooms ...-._..... T „a._. " „ �'•'_" "^�" ^ ' "'r _'^ ^. " Character of soil to a depth of 3 feet: Water table depth ' .kSEPTIC TANK ❑ Type/Mfg ! Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest Well Foundation Property Line , i LEACHING LINE ❑ No. & Length of fines Total length/size FILTER BED ❑ Distance to nearest- Well Foundation Property Line SEEPAGE PITS El Depth Size Number 1 SUMPS ❑ Distance to nearest:£ Well Foundation Property Line V DISPOSAL PONDS ❑ hereby certify that I have prepared this appllcation`and that the work will be done in accordance with San Joaquin county ordinances, state laws, i rules and reg f the San Joaquin'iLocal Health District. Home own or license en, signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not F employ any person in such manner as to became subjf) v, rkman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I c ify that in the perfo mancork f r which this permit is issued, I shalEemploy persons subject to workman's compensa- tion laws{of California "The appricant ust or II requir i r ing on re side. �j �� s� Signed Title: ��'C Date: 3 ` t a FOR DEPARTMENT USE ONLY Application Accepted by� v Date , -- f Area Pit or Grout Inspection by "" Date Final Inspection by� e f Date I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant"- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY, DATE PERMIT'NO. + EH 4324(REV.1/85] .� , s EN 1426 , o CS �r ' �s