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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT --�- 1601 E. HAZEL T ON AVE., STOCKTON, CA - I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r1 (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. 1�3a E, t j M Job Address Cit ' Lot Size P _g � 75 •- 4 Owner's Name Address ® I L� Phone II� � r � Z�Z-Z-� hone Contractr�'r"'`�� ccAddress �� License No.�-_— P — TYPE-OF WELL/PUMP: - NEW WELL❑ WELL.REPLACFMENT ❑ .DESTRUCTION -❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑, OTHER ❑ ✓r DISTANCE TO NEAREST: .SEPTIC TANK SEWER LINES _ DISPOSAL FLD. _PROP. LINE FOUNDATION AGRICULTURE WELL -_ - OTHER WELL .� PITSISUMPS- — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1Industrial EIOpen Bottom ElManteca Dia. of Well Excavation Dia. f Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i — FI Public f n Other C Delta Depth of Grout Seal Type of Grout I I Irrigation _ _,.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destructions. ❑ Well Diameter Sealing Material Itop 50'1 r } Depth Filler Material (Below 50'] TYPE OF,5EPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public ewer is I available within 200 feet.) I 4 InstallatioWwill_serve:4 Residence.;- Commercial_ Other _ ;�e.F v.r Number offiving units: Number f bedrooms ` r Water table depth Character;of,sosl to a depth of 3 feet: SEPTIC TANK Type/Mfg 1 Capacity b Q No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:' Well So _ Foundation (_0 Property Line i I f i + LEACHING LINE , No. & Length of lines Q Total lengthlsize 0 Kg I 5 FILTER BED CI Distance to nearest: Well . Foundation © PropertyLine 4- 11 SEEPAGE PITS'-,. N Depth Size_-�� (,2 _ Number *SUMPS y. Ll,,.t)istance-to nearest:''"Well Foundation Lo -;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 Diltrict. 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." Contractors hiring or sub-contracting signature �\ certifies the following: "!certify that in the performance of.the{work for which this permit is issued, f shall employ persons subject to workman's compensa- tion laws of California. The applicant call f re fired inspections. Complete drawing on reverse si a. Q Signed i t *Title: d e Date: r� da 'FOR DEPARTMENT USE ONLY ,. Ap lication Accepted by Date Area or Grout Inspection by a Final Inspection by ate`�'`J"'"—' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ;,0-Tracy ~835-6385 Applicant - Return all copies to: Environmental Health Permit/Services4\16014. Haze`Iton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUEAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO �.EH 13-24*REV.r i rs 51 /I �6 b EH 14-2e - - ny _ I ,