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I, 3 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED s (Complete in Triplicate) Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is r 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 i Local Health District. 1 f!� tot SizePM Job Address 11 City d 4 Owner's Name LL AddressI—,,_N �i' '� `S Phone Contractor &&OCC Address License No.,WM —Phone i TYPE OF WELL/PUMP: NEW WELL rW WELL REPLACEMEN ❑ DESTRUCTION ❑ 4i PUMP INSTALLATION SYSTEM REPAIR L3OTHER 7140 N f SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK — FOUNDATION _ r2�._.— AGRICULTURE WELL OTHER WELL PITS/SUMPSd INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation " Dia. of Well Casing womestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications /IrQ L— ❑ Public f] Other ❑ Delta Depth of Grout Seal d ' Type of GroutLt4 2,1�QPppioxJ Depiti"'`"1'�I`Eastern� *.�_ Surface Seal Installed by 14 irrigation 1 �• Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing.Material ltop 501 P Depth Filler Material jBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I:i REPAIRIADDITION I 1 DESTRUCTION I 1 iNo septic system permitted if public sewer is t a available within 200 feet.I Installation will serve: Residence{ Commercial Other) Number of living units: I Number of bedrooms -t € Water table depth t Character of soil to a depth of 3 feet: i ; I SEPTIC TANK ❑ Type/Mfg � � r q Capacity No. Compartments ` F ' PKG. TREATMENT PLT. ❑� �{ � # n Method of Disposal ` ' { �] Distance to nearest: Well Foundation Property line A LEACHING LINE ❑ No.'.&,Length of lines Total length/size kFILTER BED '' C1Di-stan- to nearest: Well r Foundation Property Line a SEEPAGE PITS i I Depth Size ! Number i SUMPS L] Distance to-nearest: Well . Foundation Property Line DISPOSAL PONDS ❑ ; 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 shat!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,t shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspection Complete drawing on reverse side. Title: Date: Signed X ,;•�,..� FOR DEPARTMENT USE ONLY ..._ Area Application Accepted-by_ — Date Pit or Grout Inspection by -Date&/K v Final Inspection by 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 CASH RECEIVED BY DATE PERMIT'NO. INFO I a.EH 1321 IAEV. /to 51 �� - `� I�_U� 3 EH 11.28