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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT k 1601 E. HAZELTON AVE., STOCKTON, CA Telephone(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �{j t Ii i (Complete in Triplicate) W a eY 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. Job Address C� �. f t y-� Ci Lot Size A- MC.V'F:�i"PM Owner's Name 'Nk �f' dress Phone Contractor Address License Na. Phone S 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing '' 3. r Specifications ❑ Public ❑ Other ❑ Delta 1 %'Depth of Grout Seal �= Type of Grout O Irrigation g --Approx. gepth-,_❑_Eastern.-., " 5urface..Seal,lnstalled.by.- j•°*, 1 i; Clti Repair Work Done ❑ Type of Pump' H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth'% Filler,Material (Below 501" TYPE OF SEPTIC-WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if-public sewer is , i available within 200 feet.) lY Installation will serve: Residence_�ommercial 0 er l Y Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I — _ _ 'Y�+ ` a Water table depth SEPTIC TANK gr.-Tfpe/Mfg C —Capacity 6 00 No. Compartments i PKG. TREATMENT PLT. ❑ Method of Qispo,l i •to Distance Weare .,.Well r" Foundation _ Property Line Distance to — t.1s�L .1w114 LEACHING LINE U—No. & Length of lines ' , -' _19L. FILTER BED U,Distance.to•nearestL,; —V611 Foundation Property Line , SEEPAGE PITS Depth _Size Ala '.36 Number SUMPS ❑ Distance to nearest: Well. Foundation 'r Property Line 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. 1 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 he following: "I certify that in the performance dthe work for which this permit is issued,I shall employ persons subject to workman's Compensa- tion laws alif6mid.' The applicant t call for I req ' dinctioA�omdrawing on reverse sideg Signed Title: Date: 01/ Ei j ^ FOR DEPARTMENT USE ONLY 9 ( 4 Application Accepted by Date 1- 2- + _�([" �Area r r Pit Grout Inspection by �Dt, "U—I�^� Fin In ction by Date_ —,....Additionai Comments" o-_ ___4___1_1___-.______11_'_- , i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca "8237104, t ❑ Tracy 83543&5 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P:O. Box 2009, Stk., CA SUM FEE INFO AMOUNT DUE AMOUNT REMITTED D RECEIVED BY DATE PERMIT'NO. t EH 1324'IREV. EH W28 OSS / q lip