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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT !! J601 E. HAZEL T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 i PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ;y (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 S n Joaquin County Ordinan a.54 for sewage or No. 1662 for well/ mp and the Rules and Regulations of the San Joaquin :.Local Health District. �� (F;e) _;IVIL_l/ Y T Job Address �� C11 `�°�~'� City Lot Size c�� PM J. Ei Owner's Name Address a57,5301Phone 'Contractor _Address Q �� License No. Phone 51 � ij:TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ > DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing it 0 Domestic/Private 17Gravel Pack LJTracy Type of Casing Specifications l fl Public n Other Ll Delta Depth of Grout Seal Type of Grout ii I I Irrigation —.-Approx. Depth I. I Eastern Surface Seal Installed by 4 ,i.Repair Work Done ❑ Type of Pump _ H,P. State Work Done jWell Destruction ❑ Well Diameter Sealing Material (tap 501 Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I. REPAIR/ADDiTION I I DESTRUCTION € I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial ✓ Other , •.4..g ' i '*.•- 1 Number of living units: Number f bedro ms 1 Character of soil to a depth of 3 feet: ' Water table depth t Q # SEPTIC TANK 5�--Type/Mfg -SLC. /! f cid t Capacity_/ Q No. Compartments p'PKG. TREATMENT PLT. ❑ (� r Method of Disposal �,, Distance to nearest: Well 1� . foundation 10 Property Line LEACHING LINE ❑e�No. & Length of lines a7 `"^91 r Total length/size 0 X FILTER"BED ❑ Distance to nearest: Well _1-00 :* Foundation �� Property Line S SEEPAGE PITS A Depth els Size 3 __ Number A SUMF87— �El. Distance to nearest: Well E O Foundation_ 1 f7 Property Line P 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. 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, l 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:"4 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 m ticall-for-al qui ed•inspeIq�tions'Cornplete drawing on reverse side. A ,, SigneTitle., . , � Date: FOR D ARTMENT USE ONLY Application Accepted byDate _ Area .: . a.. -g I`ON or Grout Inspection by Date Final Inspection by t Date 1 i. 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 Il FEECK It I `+ INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. j is i EH 13-241REV.rix51 EH 14.26 —7r—> 75 y