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APPLICATION FOR PERMIT 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 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. Job Address 144*Q 5• �k&LA'fl _ r'.itvL&t6rw Lot Size PM r Owner's Name ea Address Ory Phone 111417 Contract + h '/^ Address •Z _License No. PhoneL TYPE OF WELL/PUMP: NEW WELL ❑ .WELL REPLACEMENT ❑ DESTRUCTION ❑ w PUMP INSTALLATION ❑ SYSTEM REPAIRri❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES iy: `.� DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE+WELL 7 I' OTHER WELL PITS/SUMPS _r INTENDED USE TYPE OF WELL PROBLEM AREAS CONSTRUGT.1,0 SPECIFICATIONS ❑ Industrial C3 Open Bottom ❑ Manteca,-" Dia. of Well Exc vation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �� Specifications l"1 Public n Other [-A-Delta Depth of Grout Seal Type of Grout _ I l Irrigation 1 --Approx. Depthxl Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done — Well Destruction ❑ Well Diameter/ Sealing Material (top 501 f Depth IJ �- -- -----�Fiiler Material (Below 501 TYPE= OF SEPTIC:WORK: NEW INSTALLATION 11 REPAIR/A€}DITION f I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Re idenca� Commercial_ Other � Number of Living units: 77 Numbef of bedrooms k 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ) `� Type/Mfg Capacity No. Compartments PKC- TREATMENT PLT.(❑ I I Method of Disposal Distance to nearest: Well i Foundation Property Line { VEAGHlNG LINE � ❑ No. & Length of lines Total length/size CICTER-BED I ❑ Distance to nearest: Well 1 Foundation Property Line JSEEPAGE PITS 11 Depth Size 1c Number l SUMPS L"7 Distance to nearest: 1!lfell—_..1 Foundation Property Line- DISPOSAL PONDS ❑ i 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." y The applicant ust call for all required inspections. Complete drawing on reverse side. Signed X AyUyTitle: Date: FOR DEPARTMENT USE ONLY 1 2 Application Accepted by Date Area •7 ------------- Pit or Grout Inspecti n b Date �� '�Final Inspection by - `" '`� Dated Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 D Wnteca 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CABy i 1DATE SH RECEIVED i P///EyyyRMll'•NO. i EH 13-241REV.)/Mal ..._ EH 14-20 i i