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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT < &A- 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 flutes and Regulations of the San Joaquin Local Health District. I/ RG A City Lot Size PM Job Address /3-' / �J '��G-, 4[.x//4' Address —� [� 7r C � d� - Phone Owner's Name �, ;, Contractor�g.�-- r~ Address �/y0, !2 License N�77365 Phone y 7Z TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK 1c�«7 '-SEWER LINES DISPOSAL FLD.� PROP. LINE ZO j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE r TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [I Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Weil Casing Type of Casing— I/G- Specifications' ,'Domestic/Private >e Grave! Pack ❑ Tracy YP 9 ��_ Type of Grout [1 Public Public r (1 Other ❑ Delta Depth of Grout Seal YP ,r A Fox. De th 13 Eastern urface Seal installed by_ «,0`"�4n� I I Irrigation 'LIZ.- PP p Repair Work Done J3 Type of Pump ,T&r H,P. f+' State Work Done F' �f �.•-- i Well Destruction ❑ Well Diameter---------- ----- Sealing Material (top 50') Depth Filler Material-1Below:50'1 —� TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) r r Installation will serve: Residence i Commercial� Other ��,}(� Y f A� i �/ Number of living units: Number of bedrooms P Character a1 soil to a depth of 3 feet: Water table d"eptly = SEPTIC TANK El Type/Mfg Capacity No. Compartments -11' c PKG. TREATMENT PLT. 0 *�- ' 1 f ."` t Method of Disposal (' Distance to nearest: Well Foundation Property Line LEACHING.LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well r Foundation: =y Property Line Size SEEPAGE PITS 4 14 Depth � Number I SUMPS ❑ distant to o nearest: Well Foundation Property Line ! 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, andL M rules and regulations of the San Joaquin Local Health District. '! i 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 sudh 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,1 shall employ persons subject to workman's compensa- tion laws of California. The applicant must c II for ll,required inspections. Complete drawing on reverse side. Title: Date: Signed X '--4.-FOR DEPARTMENT USE ONLY `a Application Accepted by ... Date Area # �. F Pit or Grout inspection by Date le Final•Inspection by �• Date ! ) 7 t 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 AMOUNT REMITTED CK RECEIVEQ f3Y QATE PERMIT NO. INFO o +.EH 1324 IREV.1/ 5� o l�7 - p .(30 I EH 14-26 r -