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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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. n Job Address o);?36 0 City SLC Lot Size PM Owner's Name�� Address —)7 y W [ �� J�=� Phone Contractor T c L / cif Address f S� -She IeA 6d License No J OSWJ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ["1 Public F] Other F1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by —_ Repair Work Done ❑ Type of Pump H.P. State Work Done _ \ Well Destruction ❑ Well Diameter Sealing Material (top 50') tJ Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is C 3 available within 200 feet.) l^J Installation will serve: Residence Commercial Other \ Number of living units: � Number of edrooms_ c\ Character of soil to a depth of 3 feet: Water table depth Of \ SEPTIC TANK LLY Type/Mfg C — Capacity 1b No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal v` Distance to nearest: Well /co Foundation �� Property Line .200 f C J LEACHING LINE & Length of lines Total length/size ��y ®� FILTER BED ❑ Distance to nearest: Well-IP Foundation _W r Property Line -.2-L0 f 1 SEEPAGE PITS IIA- Depth 5 ( Size _ Number SUMPS t_1 Distance to nearest: Well Foundation T) / Property Line.,U& y 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 Health District. Home owner or licensed agent's signature certifies the following: "1,gertify 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 tpust call for ag required inspections. Complete drawing on reverse side. Signed Xb Title: AX)Ak A Date: ` FOR DEPARTMENT USE ONLY Application Accepted by Date / jtArea /Pit br Grout Inspection by �4zlDate 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH EH 13-241REV. 1N5, _ // - v ' �- /_ l -- �' ;'A �•f"�. EH 14-28 -_. .,..