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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address "✓I�T� iG City eZ tt Lot Size_110l,------- PM __._Owner's Namef� G�7�d AddressPhoney Contractor t`{�� _Address l License'Nog _Phone TYPE OF-WELL/PUMP: _- _ NEW WELL C]__ WELL REPLACEMENT C DESTRUCTION O _ PUMP INSTALLATION L) SYSTEM REPAIR G OTHER O DISTANCE TO NEAREST: SEPTIC TANK __ _ ..____ SEWER LINES DISPOSAL FLD. { PROP. LINE ..._— FOUNDATION AGRICULTURE WELL OTHER WELL I PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial J Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C1 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications M Public Fl Other n Delta Depth of Grout Seal Type of.Grout _.._ I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done I J Type of Primp H.P. State Work Done Well Destruction C Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I (No septic systern permitted if public sewer is _ available within 200 feet.) Installation will serve: Residence= Commercial_ O3her Number of living units: _D__ Number of badroon s�_ r Character of soil to a depth of 3 feet: �6 _l_�—__ ---.Water table depth SEPTIC TANK FT Type/Mf9 D!n )C1��r -- - Capacity._ �fl.__ No. Compartments PKG. TREATMENT PLT. Cl � ` Method'of Disposal _..... _ Distance to nearest: Well �,� Foundation _!Property Line t , LEACHING LINE LI No. & Length of lines Total ize- 1046 FILTER BED VDistance to pearest: Well Foundation ' Property Line 4 SEEPAGE PITS I I Depth Size - _' Number SUMPS CI Distance to nearest: Well Foundation Property Line 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. r 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 California." i The applicant must all for all�d _ ns. Complete drawing an revverssee side. Signed X Title: -'!'^C 1 P IA+ ' Date: 9 DEPARTMENT USE ONLY Application Accepted by . . �a - _ Date �Area 13 - . s Pit or Grout Inspection by Date --- -- Final Inspection by Date Additional Comments: f Cl Stk 466-6781 O Lodi 369.3821 O Manteca_ 823-71014 ❑ Tracy 836-6385 ; Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE ' (NFD AMOUNT DUE AMOUNT REMITTED CK CASH _ RECEIVED BY DATE PERMIT'NO. . EH 13-24 IfitV.ri n 5) EH 14-2e