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" f APPLICATION FOR PERMIT SAN .JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 FF1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1. (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �7 �f �J Job Address S' Wf r41 d 1ZcF City M e at Size PM ! fT �� +'fit-r` F _ 19:32- O • T 9FC11�- — Phone :3Z3-?Z _ Owner's Name � � _- Address . Contractor Address License No. Phone 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 l 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Depth of Grout Seal Type of Giout . � {'1 Public (_1 Other Ll Delta Dep YP — I I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ # 1 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material Ieelow 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIRIADDITION P0,DESTRUCTION I 1 IN. septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence�Commercial Z Other Number of living units: A— Number of bedrooms Character of soil to a depth of 3 feet: LO Water table depth " Gd Grl-T" . SEPTIC TANK C9�Type/Mig l ►'7 _ Capacity a#Zt6 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines }Tota! length/size E FILTER BED 94�Distance to neatest: Well Foundation Property Line x z3 / E_t} SEEPAGE PITS l 1 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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 I rules and regulations of the San Joaquin Local Health District. Home owndr or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, f 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicants must call for all required inspections. Complete drawing on reverse side. n Signed X !�""" .__ Title: Date: R DEP ENT USE ONLY Application Accepted by - - Data.,/ Y-- Area std i Pit or Grout inspection by Date Final inspection by Date Idu� Additional Comments:' 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all capias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE f INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. +.EH 13-24 IREV.i i H 57 EH 14.2e b , �"` �� S