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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE:.TON 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 11-e 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. Job Address � ! /L'�!.� i�:`t-„r Lot Size PM Owner's Name S�i�,r� � d 'c-a� Phone Contractor A._" F � "r7 Address fd' /7 icense No. uQ'' /Phones TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ ti DISTANCE TO NEAREST: SEPTIC TANK " - SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL' - OTHER WELL PITS/SUMPS _ INTENDED USE 4. 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 ❑ Public l ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. .State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is } available within 200 feet.) Installation will serve: Residence commercial 30ther Number of living units: Number o bedro s l Character of soil to'a depth of 3 feet: ��6zlw/Bt� Water table depth SEPTIC TANK e Type/Mfg Capacity /21po No. Compartments PKG. TREATMENT PLT. ❑ --4. - MOO Foundation ��Method of Disposal Distance to nearest: Well FoundationJ v(�— Property Line- - - ,� I LEACHING LINE CI No. & Length of lines Total length/size FILTER BED ❑ Distance to-nearest: Well ( Foundation Property Line I z, SEEPAGE PITS ❑ Depth Size S-X /0 X / 0 Number 4ttSAL ❑ -Distance to.nearest: WeII '®� Foundation Property Line PONDS ❑ 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. r 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." ; The applicant must caZfoII requ" d inspe ions. Complete drawing an reverse side. _ 4 ��s1iC 1� � Date:} Signed Title: _ FOR DEPARTMENT USE ONLY f f Application Accepted by `P date 1 f�� 7 Area 67 Pit or Grout.Inspection by t Date Final Inspection by Date /4' Additional Comments: O 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 AMOUNT DUE AMOUNT REMITTED t K RECEIVED BY DATE PERMIT NO. INFO "" CASH + EH 1324{REV.1/557 �.�- i •y. �^ �� ...f'7� EH 14-29 f