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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466-6781 ' PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (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 for well/pump and the Rules and R� lati�of the San Joaquin Z Local Health District. ,y, f t/O Job Address _o la QO /V /c A City Lot Size d ,.� 3 r U PM Owner's Na �`.. Address Z i Phone Contracto 1 �`�- n Address A -1 b 7 4.,,w License No.3 6 Phone_ I TYPE OF WELL/PUMP: NEW WELL EI WELL REPLACEMENT ❑ UCTION ❑ i _ __ PUMP INSTALLATION ❑ '_ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS ❑ Industrial El Bottom ❑ Mantec Dia. of Wel{ Excavation Dia. of Wel! Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T y Type of Casing Specifications fl Public ❑ Other Delta Depth of Grout Seat Type of Grout--.-- r rout__. _ I I Irrigation .-Approx. th 1 i Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of mp H.P. State Work Done— L] Well Destruction ❑ Diameter _ Sealing Material (tap 50'1 ` Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/AODIYION I ) DESTRUCTION I I (No septic system permitted if public sewer is \vim available within 200 feet.) Installation will serve: Residence--X Commercial.-_ Other _. . Number of living units: I— Number of bedrooms Character of soil to a depth of 3 feet: ' r ��7 _ Water table depth i 0 r �� r ..__....-----._...._.... Y 1 SEPTIC TANK ❑ Type/Mfg �c &fir Capacityl606 No, Compartments 7- -PKG. TREATMENT PLT. ❑ y r t� ` / Method of Disposal Distance to nearest: Well Foundation Property Line r. LEACHING LINE Ile' No. & Length of lines Total length/size 22 / O FILTER BED ❑ Distance to nearesC�� +Vell Foundation " Property Line .� SEEPAGE PITS I I Depth !A P__ ((Size or 5 Number 3 f, SUMPS L110""Distance to nearest: Well oundatio roperty Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that he 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 F 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." The applicant must riall for all require spections. Complete drawing an reverse side. Signed X Title: Date: Z Z FOR D PA MENT USE ONLY Applicati Accepted by Date Area Pit oY t"fnts�ection by Date 1 L r Final inspection by Date - L� Additional Comments: ❑ Stk 466-67$1 ❑ Lodi 369-3621 Cl 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH I +.EH13.24(REV,1/ns) EH 14-26 1 1 L 1 1