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+ APPLICATION FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 complidncu 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. Job Address �L City 1C1�/ � Lot Size PM ` Phone 1� Owner's Na&@16 - Address ��1 Phone Contractor - • _� Address G _License No TYPE OF WELL/PUMP. NEW WELL U WELL REPLACEMENT F. DESTRUCTION C. PUMP INSTALLATION SYSTEM REPAIR J OTHER P DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.-- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial C Open Bottom i7 Manteca Dia. of Well Excavation_ Dia. of Well Casing ❑ Domestic/Private ] Gravel Pack C Tracy Type of Casing _ __ Specifications FI Public n Other 1-1 Delta Depth of Grout Seal __ _ Type of Grout - I I Irrigation _ Approx. Depth I Eastern Sur/dee Sedl Installed by Repair Work Done O Type of Pump _ _ H.P. __- _ State Work Done Well Destruction ❑ Well Diameter _ Sealing Material (top 50') - - --- \, Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR7ADDITION I DESTRUCTION I INo septic system permitted if public sewer is C A��_ available within 200 feet.) Installation will serve: Residence_ CommefClat__ Other .Number of living units: _ Number of be ours dc/ Character of soil to a depth of 3 feet: ` I2`l -. - _ Water table depth 3 SEPTIC TANK LL,-Type/Mfg Capacity 32-0 CL_ No. Compartments PKG. TREATMENT PLT. L! I Method of Disposal � — Distance to nearest: Well / Foundation _�M Property Line _yLS r LEACHING LINE LVNo. & Length of lineW 60 _ Total length/size_J�(J FILTER BED L-1 Distance to nearest: Well Foundation -__ V f Property Line - SEEPAGE PITS Depth Size_ - y __- Number 3 r SUMPS : I Distance to nearest: Well 330 'Foundation - , _ Property Line__C4_4A DISPOSAL PONDS 1 1 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. 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 applican must call for required inspections. Complete drawing c; verse side. Signed X _ _ Title: ;e _ Date: a FOR DEPARTMENT.USE ONLY - Application Accepted by �— V� _ Date ^/p��— Area l Pit r Grout Inspection by Final Inspection by ` Dat i Additional Comments: _ L: Stk 466-6781 LI Lodi 369-3621 Ll Manteca 823-7164 Li Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Ha2elton Ave., P.O. Box 2009, Stk., CA 95201 lv� FEE AMOUNT DUE AMOUNT REMITTED CK S CASH RECEIVED BY DATE PERMIT NO. INFO /�f, (*) _ !X� EH 13.26 IREV >, 7V� Ou �V � 7 � V �V EH 1428