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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. p S` Job Address y "i1�} a `City Lot Size PM i I I Owner's Name 1/lJ t L 1_1;�,,,� _ Address IZ Phone-84'� —'SIB "Contractor _ low Address 9 1 Itrwriaty AC, License No.UJ)?_Z+ Phone TYPE OF WELL/PUMP:._ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER � t DISTANCE TO NEAREST: SEPTIC TANK SEWER`LINES -DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS W^^^ q ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exvation /%. J1.1 Dia. of Well Casing I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casingj — Specifications r 171 Public n Other Cl Delta Depth of Grout Seal *Type of Grout �I i Irrigation -Approx. Depth I I Eastern Surface Seal Installed by K- Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION 1 I DESTRUCTION 1 1 (No septic system permitted if public sewer is r available within 200 feet.) I. Installation will serve: Residence Commercial Other I Number of living units: Number.of bedrooms +` Character of soil to a depth of 3 feet_ Water table depth I ` SEPTIC TANK^ ❑ Type/Mfg Capacity No. Compartments 7 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size i M FILTER BED ❑ Distance�to nearest: Well Foundation Property Line SEEPAGE= PITS i I Depth I Size Number ( SUMPS ❑ Distance to nearest: Well FoundationA A Property Line ` DISPOSAL PONDS ❑ - 1 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, I shall employ persons subject to workman's compensa- tion laws of California." IfiJ gj6- �l_ The applica t m9II for all squired spections. Complete dg on reverse side. --Ii�p3 i ?. Signed Title: 1A1�1&, 4�� Tae_ Date: r r FOR DEPARTMENT USE ONLY. +� ` Application Accepted byDate A[ �S Araa Pit or Grout Inspection by Date� � Final Inspection by Date F 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 95201 i x FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO � + EH 13-211REV.t/st53 EH 14-29 '�