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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209).466-6781 a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . w i (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 Rule_s and Regulations of the San Joaquin Local Health District. - :z.» tr,r R • Job Address r �� _� '� — City 7� l©� Lot Size r / PM Owner's Named 4c ate—_— Address S�r . e _ Phone Contractor's Name /as +s�ff -�Q�-�— License No. 211-3 y3 Phone,4196 TYPE OF WELL/PUMP:w, �--NEW WELL_`❑ f s WELL REPLACEMENT ❑ DESTRUCTION 0"' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ . DISTANCE TO NEAREST: SEPTIC TANK''* SEWER LINES.,0 DISPOSAL FLD. PROP. LINE.: FOUNDATION *-R*. AGRICULTURE WELL ' OTHER WELLS PITS/SUMPST t t INTENDED USE TYPE OF WELL PROBLEM AREA .CONSTRUCTION SPECIFICATIONS J ❑ Industrial ' ❑ Open Bottom 0- ❑ Manteca Dia. of Well Excavation Dia. of W611,Casing ❑ DomestickPrivate --D D Gravel Pack-17-4,o-. �❑ Tracy' Type of Casing Specifications.- f. O-Public ❑ Other ❑_Delta ,,.,Depth of Grout Seal Type of Grout ❑ Irrigation —Approk. Depth ❑ Eastern _ Surface'Seat'tnstalled by Repair Work Done C7 Type of Pump y . H.P`� "'4� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top-60' { r Depth + Filler Material (Below,50')" '- f TYPE OF SEPTIC WORK. NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION C1 (No septic system permitted if public sewer is 3 available within 200_ feet.I". Installation will serve: Residence Commercial_ Other I t R Num eb r'of living units:_,/— Number of bedrooms Character of soil to a depth of 3 feet: -Z_ Water table depth SEPTIC TANK IKType/Mfg !°° Ze ie t J'H - Capacity /Zoo No. Compartments ,PKG. TREATMENT PLT. ❑ ti ` Method of Disposal ' Distance to nearest: 'Well' Foundation L Property Line s1 i LEACHING LINE t__�No. & Length of lines f 6_ Total length/size -2 '` 6 � FILTER BED ❑ Distance to nearest: Well A14 _ Foundation 14 Property Line . i I I 1 � -Si ;SEEPAGE PITS Depth Number� ,• ? -" � " AY i .SUMPS- w--��- -T-1B—Distance-to-nearect., -Weil M- oundation ---0 3Property-Line==S 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 shell not employ any person In such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature 1 certifles 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." - ti . The spplican at call for all required Inspectionfi. Complete drawing on reverse side u 3 Signed X Title: Date: 47 FOR DEPARTMENT USE ONLY /i i Application Accepted by " Date ! `/` Area f' 1 9- - �� Plt-0c-Gto t�lns;w on by - date Final Inspection by__ ,s �A Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 8385 Applicant- Return all copies to, Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED _CASH- RECECKS IVED,,BY DATE PERMIT'N0. + EH 1321(REV.101831 EH 14,28 w