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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (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 t 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 i Local Health District. r Job Address 524'2? City Aw<d6alt Size •— 'p PM Owner's Name [� �� — Address Phone Contractor's Name sdLicense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMPINSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ w DISTANCE TO NEAREST:-StPTIC TANK SEWER-LINES ^,. DISPOSAL FLD. PROP. LINE iFOUNDATIOI` - AGRICULTUREEWELL%_'f—0 -'OTHER WELL PITS/SUMPS C3 INTENDED USE TYPE OF WELL PROBLEM AREA,_CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.'of Well Excavation Dia. of Weil Casing ; f ❑ Domestic/Private ❑ Gravel Pack El-Tracy 'Ty`pe of Casing Specifications ; ❑ Public ❑ 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 501 ° Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONV DESTRUCTION ❑ iNo septic system permitted if public sewer is �qV 1, available within 200 feet.) V{, Installation will serve: Residence Commercial_ Other ,€ Number of living units: --,I— Number of bedrooms —R ! t r Character of soil to a depth of 3 feet: Water table depth 40 SEPTIC TAfNK �� Type/Mfg Capacity No. Compartments 1 PK& TREATMENT PLT. E-1 [ =r�" ,✓f` , Method of Disposal x J Distance to nearest: ti Well O 4 Foundation cw'?D — Property Line LEACHING LINE ,� No. & Length`of li es Total length/size t'j7 ' OF FILTER BED ❑Dista a to nearest: Well� Foundation �� Property Line�-, d ..SEEPAGE PITS ❑ Depth Size -� r, i Number SUMPS ❑Y Distance to nearest: Well Foundation Property Line ` DISPOSAL PONDS I hereby certify that I have prepared this application.and that the work will be done in-accordance•wiffi-San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. t > :7471 Home owner oriicensed 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 4r, - t ' h manner as to become subject ho workman''s compensation,laws of California:"Contractor's hiring or subcontracting signature certifiesertify that in the pe rmance ofthe-work fogy whichthis:permit Is issued;`I shall employ persons subject to workman's compense tion lawJ, The apr ygi `d"i ' cti s CompEete drawing ar3;w arse side. 4- V.!F _ / Signed Title: Date: L/L a � 57 / 441_ FOR DEPARTMENT USE ONLY Application Accepted by Date Area j Pit or Grout Inspection.by Date Final Inspection by Date 4L,y Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy v835.6385 ,.� _ j.. -Applicant- fe-Griallall copies to: EnvironmeniWl Health Permit/Services 1601 E. Hazelton Aye..-:P.O. Box 2009, Stk., CA 95201 FEE AMOUNT AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13.24IREV.10183) O 14 —9 �q q-3 70 EH 14-26