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_ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRMCT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone !2091 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete 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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. (� Job Address V00 0 mill J.- �� City Lot Size ! octexxz PM or- r �^ Owner's Name Address .3 �I"]'�.L Phone c3 Contractor dress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ Y TEM REPAIR Ll OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT E WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE C STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type f asing Specifications 1-1 Public ❑ Other Ll Delta Dept of Grout Seal Type of Grout I I Irrigation —Approx. Depth i I Eastern S fac Seal Installed by 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 INSTALLATION REFAIR! DITION i I DESTRUCTION I I INo septic system permitted if public sewer is 10("-M ,+�, 'r availabl within 200 feet.! Installation will serve: Residence Commercial _-- Other�r � V, '" X07,r 1f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: / ' L1' -Water table depth E) 12 SEPTIC TANK Type/Mfg Capacity — No. Compartments PKG. TREATMENT PLT. ❑ i Method is I Foundation r Distance to nearest: Well / Property Line LEACHING LINE ❑ No. & Length of lines Z Total length/size FILTER BED U Distance to nearest: Well Foundation? 7 Property Line SEEPAGE PITS 11 Depth _2_S_~ Size 6, Number SUMPS Ll Distance to nearest: Well I,JQ Foundation Property Line D At- DISPOSAL PONDS Ll 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, an rules and regulations of the San Joaquin Local Health D1oltrict. �. 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.Ct 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 a pplicaP must call for required 'nspections. Complete drawing on reverse side. �a Signed X Title: _CL-1 e,,l — /� Date: c� FOR DEPARTMENT USE ONLY ` Application Accepted by Date_ \,z1` <;a Area Pi or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 NOP FEE y INFO AMOt/U-NT--D�U,E AMOUNT R(EMIITTED CASH RECEIVED BY DATE PERMIT'NO. . EH 1 -24[REV.r i N si EH 144-28