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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA F Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (Complete in Triplicate) l 5 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 fot sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 5 Job Address / 7 ' t1� `�'ti "e_; ' City Lot Size " PM 1 Owner's Name Cr AP-1 - -.Address`� '� Phone Contractor=�r`��"F___ � x Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 1 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 ExcavationE Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public f l Other C1 Delta Depth of Grout Seal Type of Grout �� 1 1 Irrigation _Appfox. 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 Itop 50'1 v Depth Filler Material lBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 1 DESTRUCTION I I iNo septic system permitted if public sewer is y available within 200 feet.] F Installation will serve: 'Residence X Commercial— x Other Number of living units: Number a�bedrooms Character of soil'to a depth of 3 feet: SaN�`( f Water table depth /00�� 7 SEPTIC TANK , Type/Mfg + �ANCf�rf�"TE Capacity /(,o00 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i. Distance to nearest: Well A00+foundation 20 Property Line _ s I - - , LEACHING LINE No. & Length of lines - f g:9 LQM Total length/size f, FILTER BED �'�^ ❑1 Distance`,to nearest: Well /35 - Foundation :5 S7.1 Property Line� r ` r k3bf Number I SEEPAGE PITS I ��„Oepth 1 �S Size A I SUMPS . ❑;� Distance-to nearest: 'WeU/90� Foundation /Zo• , Property Line DISPOSAL PONDS ❑. �' e 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 I rules and regulations of the San Joaquin Local Health District.. .,"'k t.t 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 Califor ia." a . • cs k } r The applic t m call for alrre nspectiori amplete drawing an reverse side. f SignDate: 5 Signed X � � . Title: ` t t FOR DEPARTMENT USE ONLY s r Date `!` Area_6'y Application Accepted by it f Pit or Grout inspection h,F' to Final Inspection by Date !} Y 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 C K RECEIVED BY DATE PERMIT NO. INFO G f + EH 13.24[REV.i H 5) �L.J• V -)o ,V Q i W� �CFIL 0 :Y:7: i EH 14-28 LJ x