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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE.,,STOCKTON, CA - Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 h Local Health District. Job Address 6 D 4 �a� l �j City ��Lot Size PM Owner's Nameu Address _ ��"� Phone '36 10 Contractaa �'�'"Hddress License No V Y/ D Phone �/�2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll`- # DESTRUCTION ❑ - - =.--- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE � D15TANCE TO NEAREST: SEPTIC TANK SEWER LINES v DISPO PROP. LINE' FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS INTENDED USE �E-BF LL PROBLEM ARE NSTRUCTION SPECIFICATIONS " ❑ Industria! •❑ Open Bottom Dia. of Well Excavation Dia. of Well Casing ❑'Domestic/Private ❑ Gravel Pack ❑ Tracy Type Specifications FI Public 11 Oth ❑ Delta Depth of Grout Sea Type of Grout _. I I if ___-..Approx. Depth 1 I Eastern Surface Seal installed by - Repair Work Don Type of Pump H.P. State Work Done_ Well Des ion ❑ Well Diameter Seating Material Itop 50'] Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I , DESTRUCTION l I (No septic system permitted if public sewer is.- available within 200 feet.) i Installation will serve: Residence-A Commercial_ Other Number of living units: —� Number of bedroofT�s__-_-�.a 2 1 30 Character of soil to a depth of 3 feet: �1�d �'f Water table depth SEPTIC TANKf Type/Mfg W N C-UL Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well Foundation Q Property.Line i LEACHING LINE ,Wr No. &-Length of lines � yTo�tall length/size FILTER BED ❑ Distance to nearest: Well. 0 Foundation� Property line J f K I SEEPAGE PITS yr Depth � —Size Number —�-- SUMRS Distance to nearest: Well 7 O t Foundation 62 CU r Property Line I 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 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 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 Californ' 4 The applicant call for all requi d s ctions. mplete drawing on rever tr Date: Signe Title: PARTMENT USE ONLY A � Applicaon Accepted by Date o —k Ar91 ea i rout Ins tion"by Date �2 $Final Inspection bXA y Datey r Additional Comments: 211 � ❑ Stk .466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635 6385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, dill., CA 9 01 �„ t� FEE DONT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"ND. r INFO /��`l CASS �/-/� `j'( I i +.EH 1324(REV.I/X 5) ti/� ��' vim+ �` �� iyC�� V��/-` [. EH 14-26 - v