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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 well/pump and the Rules and Regulatio of the San J quin Local Health District. & �� Job Address 4 4 l City Lot Size ' '' PM Owner's Name v Address 4(1731/r/ '5—: r ,rPhone Contractor �/ Address 11?*i r Qom Licens o. SPhone QQ '- TYPE OF WELL/PUMP: NEW WELL ❑ ! WELL REPLACEMENT ❑ DESTRUCTION)❑ PUMP INSTALLATION ❑ w SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK-- SEWER LINES DISPOSAL FLD. 4ROP. LINE FOUNDATION j' AGRICULTURE. ELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WE4L PROBLEM AREA CC RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom. ❑ Manteca r` Dia. of Well Excavation Dia. of Well Casing 11 ❑ Domestic/Private ❑ Gravel Pack a ❑ Tracy Type of Casing Specifications ❑ Public ❑ at`er-- ❑,Delta Depth of Grout Seal Te of Grout r _.4 111..,. _ . . _ i" YP ElL^Irrigation `Approx. Depth _ ❑'Eastern SiAee'Seal Installed by Repair Work Done ❑ T p p ypPof Pum ' H,-P: State Work Done Well Destruction ❑ Well Dia eter Sling Matefial-(top-50`__ ", 6 Depths ; f Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALO. t N ❑ REPAIWADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is _ {�` ` • �� _ �5 available within 200 feet.) Installation will serve: Residence (Ceti rcial Other n �•- . Number of living units: °y f,fdumber,of bedrooms-- Character of soil to a depth of,91eet: r" f ?- ��_.__1 Water table depth SEPTIC TANK IDS t /Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ a Method of Disposal g Distance•to nearest Well -Foundation•- w--�-"`�-'�'PtaMrty Line LEACHING LINE k!1-_No. & Lbhitfi dIines ` '� Total length/size 20 FILTER BED ❑ Distance to nearest: tkell Property-Liner SEEPAGE PITS Depth Size 23 // Number SUMPS ❑ Distance to nearest: Well_ Foundation �� Property Line ZQ 71- DISPOSAL ;DISPOSAL PONDS ❑ 1 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 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." The applicant must call f r a ed ins ctions. Complete drawing on reverse side. Signe Title: - Date: S 7-, FOR DEPAR MENT USE ONLY Application Accepted by Date 7/00 �� Area Pit r Grout Inspection by Led Date Z' p Final Inspection by1� `��/�]F� ' � Date` ^ j. ' 4W Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT•NO. a EH1324 1REV. EH 14.28