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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) 2j'3-0 e1V- 0 2L Applicationis hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This application is r'y made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rqles and Regulations of the San Joaquin W Local Health District. ' me-ti Lot Size �� 7/��i PM �� City: e Job Address ' -r, Owner's Name Address Phone fil Contractor . Address 2 License No. 12qg2,i&13 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Af)lier SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION " _ AGRICULTURE WELL " ` —OTHER WELL PITS/SUMPS R INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS tf s C1 Industrial ,❑,(Open Bottom C:1 Manteca 'Dia. of Well Excavation Dia. of Weil Casing Domestic/Private yep Gravel Pack T Tracy Type of Casing re Specifications 11 Public ❑ Other ❑ Delta Depth of Grout Seal L Type of Grout L1 Irrigation ---Approx. Depth 13 Eastern Surface Seal Installed by z b Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter Sealirfg Material ;top 501 Depth Filler�.Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LlDESTRUCTION El (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet; .44 Water table depth SEPTIC TANK ❑ Type/Mfg '" ' Capacity No. Compartments ° Method of Disposal I PKG. TREATMENT PLT. ❑ Distance to`nearest: Wdl1 -. s Foundation Property Line k y LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. i 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,I shall employ persons subject to workman's compensa- tion laws of California." I The appliVantst call for all require 'nspections. Complete drawl reve side. t i Signed Title. bate: . i. , t i FOR DE RTMENT USE Q Y L Application Accepted by 1 Date Area I f�, -2 p Pit or Grout Inspection by Date` Final Inspection by A414 Date Additional Comments: t `q Stk 466-6781 'El Lodi 369-3621 ElManteca 823-7104 ElTracy 835-6385 Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO /t� } 1 + EH t3-244REV.1/B57 � �� 4�"/ 6s _- ii, d EH W26