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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 heroin described. This application is i made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for we11/pump and the Rules and Regulations of the Sen Joaquin Local Health District. CitYq tot Size PM Job Address Owner's Name wl 'r�.'__- �C ' (,Address . /L—,/ jI Phone I ' � _ Ss��Phane Contractor,-��.��-1'E Address_ License No..._ �` TYPE OF WELL/PUMP: ;k NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C SYSTEM REPAIR 71 OTHER L1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ ___ DISPOSAL F.LD. _ PROP. LINE . FOUNDATION t AGRICULTURE WELL ______ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ - .— j ❑ Industrial 1❑ Open Bottom ❑ Manteca t'f'Dia. of Well Excavation-__ __- Dia. of Weil Casing 1 f ' Specifications iJ Domestic/Private i�y C3 Gravel Pack f C] Tracy Type o Casing.__. Fl Public tit n Other ) r Delta -.Depth bf Grout Seal Type of Grout I I Irrigation —.Approx. Depth j I I Eastern '`-Surfack Seal Installed by - - i 1 ": Repair Work Done C1 ;!! Type of Pump H.P,� - -'z State Work Done Well Destruction U 1 Well Diameter I Sealing aterial atop f A Depth__ I. Filler AAterial ler w 50'1 .- — I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/A DITION i-?. •OESTRUCTION I ! (No septic system permitted if public sewer is available within 7DO.fest.) Installation will serve: Residence Commercial Other Number of living units: N tuber of bAdr�oorns•`�r Character of soil to a depth of 3 feet: r _ Water table depth SEPTIC TANK ❑ Type/Mfg t f7 _ a.. 4Capacity_ _ `No. L`ompartments _ - 11 r 3 Method of Disposal_ PKG. TREATMENT PLT_ n r J Distance to nearest: Well 1`6un0tion �' Property Lane . t - ti. n -.�i LEACHING LINE Y No. &Length cif—line st�_ � Y Total length/siz i FILTER BED L Distancei to nearest: Well ''`- � Foundation�� Property Line SEEPAGE PITS I I Depth _._- Size__ — _ Number 3 SUMPS L1 Distance to nearest: Well Foilnbation PropArty Line DISPOSAL PONDS P, 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 l rules and regulations of the San Joaquin Local Health District. f Home owner or licensed agent's signature certifies the fodowing: "I cdrtify that in the performance of the work for which this permit is issued, 1 shalt not employ any person in such manner as to become subject to work'man'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 requir inspec' ns. Com late drawing on traverse side. i Signed X - "- ,art Title:-- "";�t.0 _. Date: I � — t FOR DEPARTMENT USE ONLY -� �7 j q ,2 t 13 . Application Accepted by '' Date Area I � Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-8781.E ❑'Lodi 369-3621 ❑ Manteca W-7104 U Tracy', 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK \ ' FEE' AMOUNT DUE AMOUNT REMITTED CASH RECEIVED eY DATE PERMIT'No. INFO a_EH 13-24IREVr1,,K91, EH 14-2111 o66