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G APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. Job Address '1 l0 /V. �(t� r 9 Lot Size PM Owner's Name ^ 1 ,lS_ S- Address ��. ��/�I 7 .7 Ye-c;6 Phone Gr Contract 72nkJ Address (1� License Noa aJ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 1-1OTHER El DISTANCE TO NEA ES 7IC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATI AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PRO REA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca f Well Excavation Dia. of Well Casing El Domestic/Private El Gravel Pack ❑ Tracy Type of Casi Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of drooms Z Character of soil to a depth of 3 feet: 3 Water table depth s C. v r SEPTIC TANK Ij�Type/Mfg Ccr� Capacity 70C) No. Compartments PKG. TREATMENT PLT. f-) Method of Disposal Distance to nearest: Well Foundation c Property Line LEACHING LINE o. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 14 SEEPAGE PITS Depth 612 -Size q9 Number SUMPS ❑ Distance to nearest: Well Foundation _ Property Line DISPOSAL PONDS L) 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call fo Wild inspections. Complete drawing on reverse /sici (_ Signed X L-� Title: V . Date: 0 lS FOR DEPARTMENTUSEONLY i C� �'� � Application Accepted by —e- `"� Date Area l Pit or Grout Inspection by Date Final Inspection by GAG Date 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT NO. INFO CASH . EH 13-24(REV. od 14'Sle F1-7 y3 EH 14-26