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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 Regulations of the San Joaquin Local Health District. Job Address 3 (::. 5 7 City -i-cr- of Size c �aqm Owner's Name E r ZZb6 64__ Address Phone ` • � License No. ;Phone Contractor Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ; g PUMP INSTALLATION C1f SYSTEM REPAIR Cl OTHER CI ; DISTANCE TO NEAREST: SEPTIC.TANK f 3 -SEWER LINES DISPOSAL FLD. PROP,. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 5 INTENDED USE :TYPE OF WELL`"' PROBLEM AREA CONSTRUCTION SPECIFICATIONS („l ❑Industrial ❑-Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing ��} ❑ Domestic/Private ❑ Gravel Pack a Tracy Type of Casing Specifications 1'1 Public ❑YOther Cl Delta Depth of Grout Seal Type of Grout s ' Depth I I Eastern Surface Seal Installed by J I Irrigation --Approx. P. - \ � S V Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter .- - l Sealing Material Itop 501 Depth e ; Filler Material'IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I PAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is F available within 200 feet_.) Installation will serve: Residence_e Commercial Other Number of living units: —A— Number ofrbedr_ooms Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK 8'—Type/Mfg ICapacity No. Compartments �PKG. TREATMENT PLT. ❑ j / Method of Disposal ` Distance to Weare Well k Fo dation__ Property Line LEACHING LINE C4—P15. & Length of lines € � Total lengthlsize FILTER BED ❑ Distance to nearest: r Well Foundation - Property Line SEEPAGE PITS Depth _ t Sized' Number SUMPS 4 -Bistance to nearest: k Well FoundationProperty Line DISPOSAL PONDS ❑ I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and rules and regulations of the San boaquin 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." Contractors 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 I w californ' ' i 1 The applicant s coli foil all re wired specti . C mplete drawing on reverse side. Signed X Title: 110 k4 Date: r� FOR DEPARTMENT USE ONLY ,—^ �!" C.- 4 S � Application Accepted byDate 0 © Area Pit or Grout Inspection by_/("Date Final Inspection by i i Data ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 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 -AMOUNT-DUE-:-1, `AMOGNT'REMlTTE0— i CASH RECEIVEDBY DATE' 'PERMIT'NO"- '�" ' INFO a.EH 13-24 4PEV.1/ 5) 01,2--f � `//�/ EH 14-26 7a� V.lJ t �G .