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~" APPLICATION FOR PERMIT `..+ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE; TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address ` �' _ c City4(' Lot Size �� '�-��' f M Owner's Name Address ag�2. l4rtitt _ r�t1` Phone �'` env \ Contracts .L� LP Address! / License No. f Phone 7�' TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION 1-1 PUMP INSTALLATION f_1 SYSTEM REPAIR ❑ OTHER El 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 LJ Industriai ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �1 L7 Domestic lPrivate ❑ Gravel Pack E) Tracy T —ype of Casing_ Specifications (AJ 1'l Public Other [-] Delta Depth of Grout Seal _. Type of Grout i I Irrigation Appfox. Depth I I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump _ H,P. State Work Done Well Destruction Fi Well Diameter Sealing Material Itop 501 _ Depth Material [Below 50'1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 1 IEPAIR/ DDITION DESTRUCTION I I Mo septic system permitted if public sewer is Installation will serve: Residence 11__� Commercial —_ Other available within 200 feet.) Number of living units: __L_ Number of roomsr t Character of soil to a depth of 3 feet: "Lc- {1l L2 _ Water table depth _ ` SEPTIC TANK L1 Type/Mfg Capacity- No. Compartments PKG. TREATMENT PLT. Li Method of Disposal Distance to nearest: Well Foundation Property Line ,11�)` v LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED l I Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size ri Number SUMPS Ll Distance to nearest: Well L'� Foundation Property Line DISPOSAL PONDS t 1 1 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 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 applican ust tail f tall quired inspections. Complete drawing on reverse sid . `7 41- Signed X 1`-F-�-� Title: �r Date:/74941- FOR DEPARTMENT USE ONLY Application Accepted by L Date a Area ar Grout Inspection by �" Date 117 Final Inspection byr L Date 7 � Additiona4 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 95201FEE ti�` INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. ~ EEH H 16-29(REV.7/n51 ;;'�-116