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E J \l 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 Fit (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 t Local Health District. Job Address f f City' Lot Size- PM ` C J/Id -A Owner's Name_ t, .j f f Address f � Phone II License No. C2 - Contractor ��1 CC,� f`f Address .if` FIrk L �� Phone i l ont �t - 5� l TYPE OF.WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications rI Public Cl Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ V _ Well Destruction 0 Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION i I INo septic system permitted if public sewer is Iavailable within 200 feet.) Installation will serve: Residence Commercial_ ther Number of living units 0 Number ofkedroom Character of soil o a depth of 3 feet- Qat � '3� e d-4 s Water table depth SEPTIC TANK Type/Mfg A. a yam" f•" Capacity -1 No. Compartments `r PKG. TREATMENT PLT.❑ \ ( Method at Disposal Distance to nearest: Wel[2=2,e) Foundation Property Line �I LEACHING-LIN No. & Length of lines r f i Total length/size FILTER BED. ❑ Distance to nearest: Well ) Foundation C Property Line— �. SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C] 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, I shalt 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 I 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 call forMll requir ins ctions. Complete drawing on reverse side. f Signed X- �.�� ,//, Title: 61-e>61-e>l90 FOR �V`�t'�..�`��` Date: 1�M��'" FOR DEPART ENT USE ONLY {^ Application Accepted by Date Area Pit or%Groin Inspection by ate Final Inspection by Date J F Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFOL;AM70UNT DUE AMOUNT REMITTED CASK RECEIVED BY DATE PERMIT'NO. + EH EH 1424 IREV.-1 s51 .' /* �/ � � _ �u !tJ �� _ .!714