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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) l 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. # l 1 �/ Job Address /� Jam/ i Jr'Q. S'e f P&eY City 45'GA I C/V Lot Size PM F ' Owner's Name Address Phone e Contractor /71V/ h Btu/ 4 SaIr Address License No. phone 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 E FOUNDATION. AGRICULTURE WELL r OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing € Specifications I'1 Public I7 Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Sea! Installed by � € Repair Work Done ❑ Type of Pump H.P. State Work Done _ 4 f Well Destruction ❑ Well DiameterSealing Material {top 50'1 t k i { Depth Filler Material (Below 50'1 r TYPEOFSEPTIC WORK: NEW INSTALLATiIONY.I"REPA'IR'/'ADDITION 1"1 -DESTRUCTION I I-INo zepiic system permitted if public 'sewer is 4 i available within 200 feet.} Installation will serve: Residence JJ ` f Commercial Other Number of living units: ANumber of bedrooms Character of soil to a depth of 3 feet: ��•4�+9 Water table depth—00.r i SEPTIC TANK 2 Type/Mfg 10?f1C' G� T Q 4 Capacity 1 6017 No.1Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal + Distance toanearest Well IIO Foundation /Jr Property Line At? LEACHING LINE 21 No. & Length of.lines 3 — ciV ' I Total length/size I O FILTER BED ❑ Distance to;nearest: Well Foundation Property Line I SEEPAGE PITS ! I DepthSize Z X 1 C �' ' Number i SUMPS W1 Distance to nearest: Well fQG Foundation !�1✓r r Property Line r ; DISPOSAL PONDS ❑ t-.--'-.. :a I hereby certify that,( 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-,Dliltrict.. _ M Homeowner or licensed agen't'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 parson 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, tion laws of California." % I shall employ persons subject to workmari's compensa- 4 The applicant must call for.all.required inspections. Complete drawing on,reverse side. Signed X Title: I Date: p ..FOR DEPARTMENT USE ONLY ' 1 _ � ri'd Application Accepted by Date Area i A a Pit or Grout Inspectionby._ t " "" Dat Final Inspection by Date '� Y: f Additional Comments: ❑ Stk 466-6781 ❑ Lodi X369-36211' ❑ 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 t AMOUNT REMITTED RECEIVED[iY INFO INC H .� DATE PERMIT'NO. ' f-EH 73-241REV.rie5i EH 14-M �-r\ g/5 V[.�1.'�