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APPLICATION FOR,PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA N. .Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED s (Complete in_Triplicate) i 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 far Il/ and the Ryles and Regulations of the San Joaquin Local Health District. a Job Address , Ci Lot Size PM Owner's Name - -Address Phone Contractor Y ,�...� Ad - dress (/ License N0.37 l? �y Phone TYPE OF LL/PUMP: NEW WELL ❑ WELL REPLACEMENY ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL j5- FLD. PROF. LINE - ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j....� INTENDED USE —TYPE OF WELL__" i_PROBL'EMAI3EA CONSTRUCTION SPECIFICATIONS t '�❑'industrial 11 Open Bottom ❑ Manteca _Dia.rbf Well Excavation Dia. of Well Casing ' t !!! Domestic/ ❑ Tracy T p ❑ c/Private ❑ GravehPacetof Casing specifications ` ❑ Public "',�:::--,W w❑ Other-�-�.,...v...M. 13--Delta ---- _. � ; 4 f. 4 1 ' _; Depth:of Grout Seam, _ Type of Grout `r t❑ lFrigation --Approx. Depth ❑ Eastern Surface Seal Installed by t Repbir Work Done ❑ Type of PumpH.P. `State Work Done t Well Destruction ❑ Well-Diameter i Sealing Material {top 50') i Depth Filler Material (Below 50') } TYPE OF SEPTIC WORK: NEW INSTALLATION 9T REPAIR/ADDITION ❑ DESTIRUCTION'E3 {No septic system permitted if public sewer is ,// - � available within 200 feet.) Installation will serve: Residence, Commercial, Other t 9 Number of living units: Number o edroo Character of soil to a depth of 3 feet: +•-.^ F + Water table depth Q I ""SEPitC TANK—Type Mfg— -- -. Capacity ) ' No. Compartments . PKG. TREATMENT PLT. ❑ ` f�" ,� Method of Disposal Distance to nearest: Well- Foundation � Property Line/0 LEACHING LINE No. & Length of lines T tai length/size FILTER BED ❑ Distance to nearest: Well undationd +r property Line l � SEEPAGE PITS ❑ Depth sNumber R SUMPS ❑ Distance to nearest: Well b { Foundations Property Line DISPOSAL PONDS ❑ i 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, L 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,l shall employ persons subject to workman's compensa tion laws of Califo " The applican ust,c for all requir d i spec s. ompeta drawing on reverse s! ? t � 1 Signe Title: --- Date: FOR DEPARTMENT USE ONLY, Application Accepted by '* ^ .� Date Area Pit or-Grout Inspection by ? ate Final Inspection k;y Date Additional Comments: ' As 4 ❑ Stk 466-6781 ❑ Lodi 3699-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE AMOUNT DUE AMOUNT REMITTED r Irr R INFO CASH RECEIVED 8Y DATE PERMIT NO. 4 s f + EH 13-24(REV. /a 5r EH 1425 . ��i 8SS; �PQ