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I 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 Ordinancq No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /� x Job Address City L6N 1 Lot Size " PM ^ � _ � Owner's Name _ Address �g Phone 3.��^ Contractor � Address_L215_1 S D�Kf` License N0.30,52-Zl Phone -36 3f TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT C DESTRUCTION r-7 PUMP INSTALLATION L 1 SYSTEM REPAIR D OTHER CJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial C Open Bottom C. Manteca Dia. of Well Excavation __ Dia. of Well Casing O Domestic/Private CI Gravel Pack l, Tracy Type of Casing _ _ Specifications r'l Public -1 Other I 1 Delta Depth of Grout Seal Type of Grout _- I I Inrgdtion Approx. Depth 1 1 Eastern Surface Sedl Installed by _ Repair Work Done i7 Type of Pump ___-. H.P. __ State Work Done Well Destruction -1 Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 — IYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ; I DESTRUCTION 1 1 INo septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence I,-,' Commercial - �ther _ - — Number of living units: -A— Number o r ems Character of soil to a depth of 3 feet: 0 Water table depth I SEPTIC TANK V Type/Mfg D AICL Capacity 3,260 No. Compartments PKG. TREATMENT PLT. 11 _I Method of DDlisssppp�000JsaIPO Distance to nearest: Well IC Foundation Property Line LEACHING LINE IT'-No. & Length of lines Q Total length/size- FILTER BED 0 Distance to nearest: Well IdnA Foundation � Property Line SEEPAGE PITS Cl--Depth OSI Size Number SUMPS : I Distance to nearest: Well3,� Foundation —?A_11 Property Line ((1v 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, ander rules and regulations of the San Joaquin Local Health D3trict. 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 Califorrua." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applica must�Ilired inspections. Complete drawing oh ire/verse side. Signed X _---- -___---- Title: (� o.00 --- Date: �f` --- FOR DEPARTMENT USE ONLY Application Accepted by Date / — 0 Area 12 _ p Pit Grout Inspection by Date` =� Final Inspection by Data 6 g Additional Comments: Cl Stk 466-6781 Ll Lodi 369-3627 3 Manteca 823-7104 Cl Tracy 835-9385 -` Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DA//TE PERMIT NO. Nis . EH 13-24(REV.is M5� ��irGv �C.�.O� �•f/� !�� 9� W 1`f� EH 14 26 ✓