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M APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telepttorle (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED i (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 f 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 VAoOor Cit Lot Size / PM Ile Owner's Name Address - Phon 3 -25193 Contractor Address 624 67 fi� License No. Phone ��/ TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Ir PUMP INSTALLATION ❑ i SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES J DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial p ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well 1 Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracyi Type of Casing Specifications ('] Public i n Other D Delta Depth of Grout Seal + Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed Repair Work Done ❑ Type of Pump H.P. � 1. tate Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 i i I� Depth Filler Material (Below-50 I mac. TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION [-h DESTRUCTION I I INo optic system permitted if public sewer is n availtiie within 280 feet.) Installation will serve: Residence Commercial A Other i � Number of living units: Number Broom , D � '� Character of soil to a depth of 3 feet �'� Water table depth t�/,, SEPTIC TANK ❑ Type/Mfg I Capacl N6. Compartments PKG. TREATMENT PLT. ❑ "M shod'of Disposal 1 Distance to nearest: Well Foundation��A Property line _---_ LEACHING LINE 1EI�No. & Length of lines i 0 t r Total length/size �U FILTER BED ❑ Distance to nearest: Well_ 67 Foundations o Property Line 4 I SEEPAGE PITS 14r Depth v�.-0~ Size 34 Number- SUMPS Ll Distance to nearest: Wel! 19Q f Foundation p �— Property Line DISPOSAL PONDS ❑ ! hereby certify that I have prepared this application and tOat the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health,0Mrict. Home owner or licensed agent's signature certifies thdfollowing: "I certify that in the performance of the work for which this permit is issued,I shall no't> i employ any person in such manner as to become subject 45j workman's compensation laws of California."Contractor's hiring or sub-contracti 9 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. mpensa- . tion laws of California." The applicant; ust cal1 for all req fired inspections. Comp/ to drawing on reverse side. � I ." /� /Q Signed X Title: lQeloyk_l Date: FOR-DEPARTMENT USE ONLY j = -6- � Application Accepted byDate Area 411 Pit r Grout Inspection by Date incl Inspection I �� Date Pit ,Additional •Additional Comments: ❑ Stk .466-6781—O-Lodi-369-3621—El Manteca 823-7104- R Tracy-835-6385�- - Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95281 FEE AMOUNT DUE AMOUNT REMITTED CASH -RECEIVED BY DATE PERMIT"NO. ' INFO �] /� H r.EH 13.24MEV.1/951 , �0� �J �r % ' EH 14-26 / �+`� i / �