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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. Job Address '96'(10 ��lilvr,e City I/ Lot Size 1b3A1V(.;, PM I Owner's Name �� C- Address �l�liOhC Phone "" '� Contractor � �.�.y Address 4w AO 41! License No. Phone_ + g i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP"INSTALLATIONF(3 -SYSTEM-REPAIR'-❑- — -�------'OTHER ❑'-^-- V DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD. _ "� PROP. LINE, t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Indu trial_, _ ❑ Open`Botton?_,F].-Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑,Tracy Type of Casing Specifications l •-� ('l Public Ll Other ❑ Delta Depth of Grout Seat Type of Grout � I I Irrigation _-Approx. Depth I I Eastern Surface Seal Installed by e _ Repair Work Done ❑ Type of Pump H.P. — ---- _-•State-Work Done } I Well Destruction ❑ Well Diameter Sealing Material (top 501 � Depth Filler Material (Below 501 TYPE OF SEPTIC.WORK: NEW INSTALLATION ['I REPAIR/ADDITION [ DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence_ -Commercial Other Number of living units: Number of bedrooms y Character of soil to a depth of 3 feet: Water table depth " SEPTIC TANK ❑ Type/Mfg Capacit ="'IL' Compartments PKG. TREATMENT-PUT-:.B �-�-- r` t�``" .9 -..� Method.,of Disposal { Distance to nearest:., Well Foundation Property Line ' LEACHING LINE & Length of lines _ Total length/sig �rK y 1 ► FILTER BED 1] Distance to nearest: Well Foundation /O Property Line r s _ _ r, SEEPAGE PITS (4 Number v K SUMPS Distance to nearest: Well Foundation !C Property Line !� DISPOSAL PONDS ❑ F 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. t , 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, 1-shall not employ any person in such manner as to become subject to workman's compensation laws of Cafifor'nia. 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 California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X __�a��+-. � -ar� Title: Date: S-27 .8 T FOR DEPARTMENT USE ONLY ; Application Accepted by Date Area 5fio-) Pit or Grout Inspection by A AMA P11 Date I Final Inspection by 11 -Date { Additional Comments: 0 Stk ;466-6781 ❑ Lodi, 369-3621 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT-NO. +-EH 1324(REV.I i H 5) EH 14-29 1(J