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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAWFROM-DATE,ISSUED i1 {Complete in Triplicate} i k a•K .'.ri i. v,3 f 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. f v Job Address r City � �Lot Size ' Zt :i, PM Owner's Name ?� rass - `- -^ Phone - C> a - ContractorAddress 7-.0 " License Na. ��}�__,� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ _DESTRUCTION ❑ II PUMP INSTALLATION❑ SYSTEM REPAIR ❑ OTHER ❑. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _ �� ', AGRICULTURE WELLOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA`*CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca 'Dia. of Well Excavation �. Dia. of Well Casing I ❑ Domestic/Private __t0 Gra Pack ❑1.Tracy'""��^°-, `Type of Casing Specifications F-1Public Ll Other ❑ Delta 413e th of Grout Seal:� x,"�'; P Type of Grout I ❑ Irrigation --Approx. Depth ❑..Easter^ � V"Surface Seal Installed by � Repair Work Done ❑ Type of Pump H.P. + State Work Done j Well Destruction ❑ Well ' D'iarneter 1 f .f f _ ea�l�g Material (top 50'1 -of Depth 1 Fillers Material [Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION. DESTRUCTION E3 (No septic system permitted if public sewer is �3 _Y available within 200 feet.) Installation will serve=Res'idence � Commercial , Other I e1 Number of living units; Numbe of bedrooms Character of soil to a depth of 13 feet: SEPTIC TANK El Typre/Mf t _.. 1 '� 9 Water table depth Gapacity-- � �l No. Compartments PKG. TREATMENT PLT. ❑ l �, r- Method of disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ila---Noy & Length of46es 4 Total length/size FILTER BED ❑ Distance to nearesf: Well Foundation_lid Property Line ,,SEEPAGE PITSSize E�� Number SUMPS ❑ Distance to nearest: WeilFoundation C= perty Lin Proe DISPOSAL PONDS El !�' r 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."Contractors 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 r gluired inspection Co tete drawing on reverse side. Signed Title: Date: `l f iij. d FOR DEPARTMENT USE ONLY Application Accepted by Date rg t6 Area Q� Pit or Grout Inspection by Date 0'- Final Inspection Date — 3U-- Additional Comments; !�I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 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 REMITTED CK# -CASH RECEIVED 9Y DATE PERMIT'N0. T, + EH 13-24(REV.i/a5) PDti� � EH 10.26 f�ylZ'tL_,P 7 6=7 I f