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i _ APPLICATION FOR PERMIT { r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 ei(l�a t pplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Reg tins h Joaquin Local Health District. r– 'k104111 Lot Size C rr.r PM Job Address Q C { City S'f , , �QJt C4P4- �A Address 2 �1' L-rl�w a .0,70"Olt',,Phone Owner's Name y`r� i . �. Contractor Address License No. Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial C3Open Bottom ❑ Manteca Dia- of Well Excavation ❑ Domestic/Private ❑ Graver Pack ❑ Tracy Type of Casing Specifications FI Public n Other n Delta Depth of Grout Seal Type of Grout I i Irrigation _..Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work l ..Done_ r� Sealing Material (top 501 �y Well Destruction ❑ Well Diameter g Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION A REPAIR/ADDITION 1 1 DESTRUCTION l I (No septicwithin tem permitted er fitted if public sewer is availableInstallation will serve: Residence–L-_'Commercial_ Other Number of living units: / _. Number of bedrooms a / Character of soil to a depth of 3 feet: JZ,,d Water table depth SEPTIC TANK Type/Mfg Co c s^e L Capacity_— No. Compartments Z Method of Disposal _fit.. PKG. TREATMENT PLT. ❑ Distance to nearest: Well /0 a Jr— Foundation Property line�f� LEACHING LINE No. & Length of lines Tgtal length/size�61 >a i FILTER BED [3 Distance to nearest: Well DO Foundations .5 Property Line �r, SEEPAGE PITS I I Depth Size Number SUMPS t1 Distance to nearest: Well Foundation Property Line 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 Hearth District. ify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I cert employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature 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 s call for L requiredins ctrons. Complete drawing on reverse side. Si nod �n .-8��-- Title: Date: �^ g FOR DEPARTMENT USE ONLY 'Q Application Accepted by ` Date 19-4/_O � _ Area D iN � / _ _ Date Pit or Grout Inspection by Date Final Inspection by 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. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO �7 EH 13.24(REV.r r R 5) � ' EN 14-26 L