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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. 7 Job Address D Z City Lot Size `� x�� U PM Owner's Name [ ._. ddress 2a ioaoz - Phone � [�Contractor ddressP4& License No.7 Phone 7 TYPE OF WELL/PUP: NEW WELL El REPLACEMENT ❑ DESTRUCTION ❑ M PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK " — """SEWER LINES -.DISPOSAL FLD. "' PROP. LINE FOUNDATION AGRICULTURE WELL `; `OTHER"WELLPITS/SUMPS INTENDED USE TYPE OF WELL.mmPROBLEM AREA CONSTRUCTIO76PECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of We1,1,Excavation Dia: of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout,Sea9'1 Type of Grout ❑ Irrigation -JApprox. Depth ❑ Eastern Surface Seal Installed by _ Repair Work Done 171Type of Pump H.P. State Work Done Well Destruction ❑ Well Diarlter Sealing Material (top 50'1 ' '� All" . ' 'I Depth ; Filler Material (Below 50"1 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 'REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is { ■ available within 200 fret.) v Installation will serve: Residence Commercial.____e�_�__Othet Number of living units: Number of bedrooms,— }� I Character of soil to a depth of 3 feet: Water table depth i. SEPTIC TANK ❑ Type/Mfg Capacity _ 3�._-_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/silt FILTER BED ❑ Distance to nearest: Foundation Property Line J SEEPAGE PITS [ Depth Size _N mbar r SUMPS ❑ Distance to neo est: Well Iirll►' Foundation Property Line : DISPOSAL PONDS ❑ i 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. Ix- Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the wJrk for which this permit is issued, I shall not employ any person in such manner as to become subject tqworkman's compensation laws of California."Ccntractods hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which thin-permiCis issued,I shall employ persons subject to workman's compensa- tion laws of California." The applic must call for all required ins ctions. Com ate drawing on reverse side. f 4 1tle:- Date: Signed -- —�_-_ _--- t �. FOR DEPARTMENT USE ONLY f Application_Accepted by ( f �M. +� -- - - Date Area ' t A Pit n ction by Date vow final nspection by Additiopal Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104,. ,` ❑ TNcy 835-63% Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haiegon Ave., P.O. Box 2009, Stk., CA 95201 4 S FEE AMOUNT DUE AMOUNT REMITTED CK*CASH I-RECEIVED BY DATE PERMIT NO. INFO + EH 1324(REV.1/851 �Q a� �r 5l '�{� �� EH 14-2e