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a kO 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 ' City of Size ° PM Owner's Name Address , Phone I f Contractor t Address tba it' L":cense No. Phone 9 ,dl" 4ieTYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES A' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE-WELL OTHER WELL—.PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIpN SPECIFICATIONS ❑ Industrial ❑ Open'Bottom -❑ MantecaDia. of Well Excavation Dia. of Well Casing ' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (•1 Public ❑ Other 177 Delta Depth of Grout Seal Type of Grout r _ I Irrigation —._Apprbx. Depth I I Eastern Surface Seal Installed by a Repair Work Done 0 Type of Pump H.P. +�. State Work Done w m � Well Destruction ❑ Well Diameter -. " Sealing Material (top 50'I - Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION Al DESTRUCTION I I (No septic system permitted if public sewer is ravailable within 200 feet.) \ Installation will server Residence_ly__ Commercial Other C Number of living units: ( Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Q Type/Mfg _ s �?3Y1�, Capacity _ No. Compartments ` ! PKG. TREATMENT PLT. ❑ .11 Method of Disposal I �1 Distance to nearest: Well--F�61 Foundation_I f7 f Property Line 1 LEACHING LINE No. & Length of lines - s kG • 7otallength/size FILTER BED ❑ Distance to nearest: Well_ B < Foundation Property Line SEEPAGE PITS ' � r f Depth .� Size Number 6n 4e SUMPS Distance to nearest: Well DISPOSAL PONDS ❑ _ Foundation- 1), Property Line 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: 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as,td 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call for all re specti S. Complete drawing on reverse side. Q Si �=a�-' 0 Tide .Date: f _ FOR DEPARTMENT_ USE ONLY Application Accepted by _ x R Date 's t Area Pit or Grout Inspection by Date Final Inspection by S J�� L Date 5 i� Additional Comments: i f ❑ Stk 466-6781 ❑ Lodi, 369-3621 ❑ Manteca 823-7104 ❑ racy 835- j � Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltdn Ave., P.O. Box 2W9, Stk., CA 95201-i or c-,--/ � Y c.'--e�r•7.*=�.a-;t�'� fir- 2 FEE AMOUNT DUE AMOUNT REMITTED A RECEIVED BY DATE PERMIT'No. CK 4 INFO _r GASH � S +.EH 13-24 iREv.t i is 51 / EH 70-28 111✓✓✓ CC!! (f /rte/^`/ CCY/J �f