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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) a 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 Z Job Address 1.1�' City Lot Size PM Owner's Name _ -- Address/ �'�✓' — / /n.` Phone 3 ITContractor . dress r .) License No. c� �: Phone r 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-I RI � L� . . FOUNDAT,IQfV -AGCUL`TURU EWELL OTHER WELL PITS/SPS INTENDED US£,, TYPE,OF.WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications r f'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout h I I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by '- Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBe low 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIO DESTRUCTION I 1 fNo septic system permitted if public sewer is u� __ aila le within 200'feet:l Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms timet %� - Character of soil to a drrpth of 3 feet: ,a -. Water table depth SEPTIC TANK i❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT.10 r, Method of Disposal + Distance to nearest: Well FoundationLine !.- ^. N or 3 arc , �� • � ''�" y �, LEACHING LINE P No. & Length of lines Total length/sire FILTER BED ❑ Distance to dearest: Well 1 Foundation _ � `Property L'iiSeIT SEEPAGE PITS {I 1 Depth ` SizeNumber SUMPS L1 Distance to nearest: Well—--I j Foundation Property Line DISPOSAL PONDS ❑ k I hereby certify that I have prepared this application and that the'lwo;tk will be done'in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin-L=ocal Health Distract. i =_. Home owner or licensed agent's signature certifies the follow'ing:f'i ertify that in the performance of the work for which this permit is issued, I shall not employ any person in such mannerlas to becorhe subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature E certifies the following: "I certify tha�in the performance of the work for which this permit i�issued, I shall employ persons subject to workman's compensa- tion laws of Galifgrnia." T a ptic a must call fnr ail aqui d Ins Ions. Comp)te..drawi g on reverse side. t Signe i �� "Title i ��r�r +--1 Date: go FOR.PfPARTMENT USE ONLY by Date AreaApplication Accepted Pit or Grout Inspection by! `; Data Final Inspection by Date 7r Additional Comments: G ❑ 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 F t, )NFO AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY FEE +��jjj DATE PERMIT'NO. .,EH 13-21(REV.t i H 51 . � ,,, v EH 11-28 / /