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N. 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 Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. y Job Address Cit I dln/ ^L_ Lot Siz PM Owner's Name7:Tl r S7Address; ,-� '+ - _ - Phone o Contractor's-Na �-- — - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [7L DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES t DISPOSAL FLD. PROP. LINE .w hWJ FOUNDATION � AGRICULTURE WELL OTHER WELL-i- PITS/SUMPS INTENDED USE TYPE OF~WELL ;.PROBLEM AREA CONSTRUCTION,SPECIFICATIONS .f { 1 ElIndustrial ❑ 'Open Bottom"lF❑ Manteca Dia. of Well Excavation's Dia. of Well.Casing ❑ Domestic/Private ❑!Gravel Pack ❑ Tracy Type of Casing ) { Specifications ❑ Public ❑ Other ❑ Delta ` Depth of-Grout Seal Type of Grout a1 : ; I 5- r LI Irrigation �Approx. Depth ❑ Easte`�ri SuriaceZal Installed by - i Repair Work Dane ElType of Pump H.P. State,Work Done Well Destruction ❑ We1I Diameter -----Sealing Material {top 50'1 'f Depth Filler Material {Below 50'1 v - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION *�-D,ESTRUCTION L3 (No septic system pefmitted if public sewer is �i available within 200 feet.) { �� Installation will serve: Residence `T Commercial -�'~Othgr 1 Number of living units Number of bedroom Character ofasoil to-a depth,of 3 feet: Water table dept SEPTIC TANK ❑ Type/Mfg , l ,Capac No�'Co p rtments 1 PKG. TREATMENT.'?'UF- ❑ .- "� ,' _ P 1 l'Method�of Disposal Distance.to nearest: Well x rFoundation Property`Line_ :. � �. '� _/' � �. fires �•:..r.� �. LEACHING LIME ° ' x lNo. & Length of lines - �a =Total length/size -S4. FILTER BED } ❑ 'Distance to nearest: Well 1'�a , Foundation Property Line SEEPAGE PITS ❑ Depth Size Number_ t • t5-=;. SUMPS ❑ fDistance to nearest: Foundation * Property L�ne, ' .. t DISPOSAL PODS ❑ l i �r hereby certify that I have prepared this application and that the work will be done in a dance with Sen Joaquin county ordinances, state laws, and rules and regulations of the SanJoequin-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 jemploy any person in such manner as to become subject to workman's compensation-lavae•of.Galifornia."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 laws of Californi ;. 1 Vlly% r Tr he applicall red ins ctions. Complete drawing on rever . Signed �. Title: J Date: FOR DEPARTMENT,USE ONLY -:.�- ----� I . r Application Accepted by Date Area, Pit or Grout Inspection by Date Final Inspection by Da I—�� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 anteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stir., CA 95201 i FEE AMOUNT pUE AMOUNT REMITTED CK RECEIVED BY DATE PERMWAO. INFO '�!r CASH +EH 1324 IREV.10/831 1 0 Cr// q- IA� �- '5;b EH 14-26 11