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t ra 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. en Job Addres w, Cit / Lot Size 0 C PM k Owner's Name Address 2 !;�( LO l / � Phone / /S-_-`131<7 Contrac r� ddfess j r rLicense N =61o's Phon 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 FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , )t ❑ Industrial ❑ Open Bottom ❑ Manteca ;—'11 Dia. of Well Excavation':- Dia. of Well Casing t ❑.Domestic/P.rivate .-__❑ Gravel.P_ack_. ❑-Tracy-_ __ „_Type of Casing -_ _ _-.Specifications f'l Public F Other C) Delta Depth of Grout Seal Type of Grout I f Irrigation --.Approx. Depth I. 1 Eastern Surface Seal Installed by ' Repair Work pone ❑ Type of Pump ! H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depthyrf Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTAL�A'TIONREPAIR/ADDITION I I DESTRUCTION f I (No septic system permitted if public sewer is 1�` available within 200 feet./ Installation will serve: Residence_ Commercial Other ' Number of livingunits: _/_ Number _.edro ms 4 Character of soto a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg *, Capacity/gyp® No. Compartments PKG. TREATMENT PLT. ❑ 1 ! Method of Di osal Distance to nearest: * t Well ©© Foundation-._.�,� Property Line LEACHING LINE No. & Lengthof lines ! Total length/size <A0 X 7 Eli FILTER BED Distance to,neatest, 'A Well .._..__ Foundation Property Property Line __.__._—_ SEEPAGE PITS Depth Size Number SUMPS t CI Distance to nearest: Well Foundation f 1 Property Line—, h DISPOSAL"PONDS`"' ❑,.rte" ' _, I' I hereby certify that I have prepared this application and that thevrork Will-be done in accordance with San Joaquin county ordinances, state laws, and rules enol iregulatioris,of the San Joaquin_Loca_ l Health District.1.4 _ r i Home owner or licensed agent's signature certifies tKa-following: "I certify that in the performance of th�'work for which this permit is issued, I shall not., employ any person in such manner as to become subject to workmari'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 corrpe_nsa;r tion laws of California." The applicantst call forMd inspections. Complete drawing on,reJ7T. 0Signed XTitle,'� _ _ _ _ Date FOR DEPARTMENT USE ONLY _ a Application Accepted by Date Area f Z Pi or Grout Inspection by ae inal Inspection by-_T_-_<:.,9 �/ / �ruJ� Dates Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ 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 CK RECEIVED BY n DATE PERMI7'NO. +.EH 13-24(REV, 51 2_0 _(?�3�� EH 1426 v 1 I T r