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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (2091 466-6781 9 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. i . Job Address City S77e Lot Size A AC PM I Owner's Namep S Address Phone r Contractor FLS yam_ do Address N. Fig ;7' License No.�7 26 L 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 El Industrial El Open Bottom l--_❑ Manteca Dia. of Well Excavation Ilia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ElTracy- Type of Casing Specifications [ I Public r . f7 Other F(l Delta�_��.�aepth of Grout Seal Type of Grout / 1 11 Irrigation --Approx. Depth /l I Eastern surface Seal Installed by Repair Work Done ❑ .Type of Pump/ f� H.P,.° - '� � State Work Done _ Well Destruction 71Well Diameter _Sealing Material (top-50'1 t Depth Filler Material i13elow 50'i TYPE OF=SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION,(.I DE=STRUCTION-i-l_(No sepEic-system permitted if public sewer is �' t4 available within-1200 feet.) Installation will serve: Residence ' Commercial p^ Other " �� ¢ Number of living units: Number of bedrooms y L f`� "t "�- _Wate'tapble de th Character If soil to a depthh of 3 feet: d f - SEPTIC TANK li Type/Mfg �� 'II 1� � ' L� �"` `, Capacity Ia[9 �`- Na.lCampartments PKG. TREATMENT PLT. ❑ ` + �' k *t - Method of Disposal Yf j r �� Distance to nearest: Well �T.�Founda� ti l 0�T Property.Line �U LEACHING LINE No. & Length of lines* S' f' s Total length/size rX FILTER BED Of Distance to nearest: f Well 4 ODS Foundation l_ Property Line SEEPAGE PITS (: Depth Z�1 Size 3� _ Number,— SUMPS umberSUMPS Cl Distance to nearest` Well._.__�i'O' Foundation 71f /Property Line 7�� f f DISPOSAL PONDS 1 CIF' I hereby certify that I have prepared this application and th t•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. ' _? I' �r Home owner or licenied agent's signature certifies the.following: 'fkertify that in the jperformance of the work for which this permit is issued, I shall not employ any person in such manner as.to'beconie stibiect'tto.workrran'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 must call for all required inspections. Complete drawing.on-rreve_s[sid8 / Signed X �•—•� _ � _-Title: Date: -7 ('i-rvirt «O FOR DEPARTMENT USE ONLY Application Accepted by � `" Date A �Z-0 Area % tl 711; YX._ Pit or Grout Inspection by /J Date Final Inspection by Date V Additional Comments: i ❑ Stk 466-6781 © Lodi 369-3621U ❑ 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 ASH RECEIVED BY DATE PERMIT-NO. INFO *"EH t3-24(REV.1/K 5) EH 14-26 ! )))!)1111��-