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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1062 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.` /� r Job Address ` -7 LS r� 1 kb a, City Lot Size PM Owner's Name 7 Address r7 Phone Contractor L Address-F02 02 `��f MR-A License No�� 7/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Ir 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 rr -11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing .(C` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ ` I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by ljlll�� Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIONY REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is (� available within 200 feet.) _\ Installation will serve: Residence K Commercial_ Other r Number of living units: �_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TXKK - ❑ Type/Mfg P31'Z Capacity No. Compartments PKG. TREATMENT PLT. ❑ - F'7- � Method of 7Disposal Distance to nearest: Well-_ Foundation Pro -F�- party Line LEACHING LINE No. 8 Length of lines ''^ Toottallllength/size a fE f V FILTER BED ❑ Distance to nearest: Well O d, Foundation 6L6 F7' Property Line SEEPAGE PITS 11 Depth Size Number ` SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di§trict. 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 subcontracting 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 must call for all quire mspectio Complete drawing on reverse side. Signed X t / Title: Date:Date: /—�[ ✓I�IU '/,� ARTMENT USE ONLY Application Accepted by � � �-�✓ Date Area J��—Q�� Pit or Grout Inspection by Date Final Inspection by Date? A.✓ 11i.. Additional Comments: ❑ Stk 466-6701 ❑ Lodi 369-3621 ❑ Manteca 8234109 ❑ Tracy 935-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT NO. INFO C H �/ �.EH 1324 REV.tins) f� atLh� �'7 •L�� SCA EH 1428 / O div