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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Fi 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 Regulations of the San Joaquin Local Health District. FJob Address �� City Lot,Size h Owner's Name K 1a`.l P.-_^ r;� Address '31 Phone r CICS ddress � License No. Phone Coniraclar, L) t� Yl t` L I r TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i 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 Weil Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications {w M Public ❑ Other f1 Delta Depth of Grout Seat Type of Grout' t I Irrigation .Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ I F Well peshction ❑ Well Diameter Sealing Material (top 501 Depthtiller Material Ieelow 50') — t TYPE OF SEPTIC WORK: NEW INSTALLATION - EPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Re -dente—L'—Commercial— Other i Number of living units: Number of bedrooms-.3-- Character of soil to a depth-of 3 feet: C L Water table depth SEPTIC TANK hype/Mfg Comr v7ftl& CapacityZ 4MW_. No. Compartments PKG. TREATMENT PLT. ❑ / Method of NsaQsalmi Distance to nearest: Well/—M M Foundation Property Line I I � LEACHING LINE fRr'1i15"& Length of lines Total length/size . , FILTER BED ❑ Distance to nearest: Well , Foundation Property Line SEEPAGE PITS l Depth 2-15i -Size Nu t)Ier SUMPS L7 Distance to nearest: WeU--lam, Foundation - - Property Line DISPOSAL PONDS ❑ ! hereby certify that I have prepared this application and tha 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 shall not I employ any person in such manner as to become subject to workman's compensation laws of California Contractor's hiring or sub-contracting signature c Ties 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 law alifo 15 . The applic nt f call fora req ' drawing on verse side. r � s Sig itle: Date: FOR DEPARTMENT USE ONLY r Application Accepted by Date Area it or Grout Inspection by Date Final Inspection by Date + + A$ditional Comments: Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH dl F r.EN 13.24 MEV.l i n 51 j T,� +I EH 11-28 C/ 1 Z&Z �C 1