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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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 r eCity4dj""Lot Size / PM Owner's Name Address6 ;�L $hone I'/ - ` tl�4 �'.S / 9 9 D2 Contractor ddress icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. _ PROP.-LINE FOUNDATION A ICULTURE L OTHER WELL PITS/SUMPS INTENDED USE _ TYPE OF WELL PROBLEM A E CONSTRUCTION SPECIFICATIONS W ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing Specifications ` 1-1 Public ❑ Other elta Depth of Grout Seal Type of Grout _ I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Ts Well Destruction ❑ Well Diameter Sealing MALal (top 50') Depth Filler Material {Belo ') TYPE OF SEPTIC WORK: NEW INSTAL TION I REPAIR/ADDITION D TRUCTION I 1 INo septic system permitted if public sewer is 3, -// adabl ithin feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms _ o Character of soil to a depth of 3 feet: Water table depth - SEPTIC TANK ❑ Type/Mfg iv Capacity/20 IQ No. Compartments PKG. TREATMENT PLT. ❑ � ,,�� Method of Dispo aLl_ Distance to nearest: Well470k, undation Property Line LEACHING LINE ❑ No. & Length of linescl- Total )engthlsize Z i FILTER BED ❑ Distance to nearest: Well_ oundation Property Line IV 0 - _W___ C��f 09. SEEPAGE PITS I 1 Depth Size N�``'"r//upn4er SUMPS Distance to ne st: Well oundation��Q[[f'f�--CC- Property Line DISPOSAL PONDS El11re 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 fallowing: "I certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa- tion laws of California." The applicao must tail fro.all required inspections. Complete drawing on reverse side. Signed X Title: _ .14 ZrsM A�fl Date: FOR DEPARTME SE�ONLYif A lication Accepted byA11; Date — U 1 f Area c� Pit r Grout Inspection by147A Dat Final Inspection by Additional Comments: ❑ 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 INF AMOUNT DUE AMOUNT REMITTED C SH K 0 RECEIVED BY DATE PERMIT'NO. +.EH 1}24 ltrpV.1/H51 �� I� 7") ` � 171 t�EH 14-2a VVV i {{{{ 1w�]