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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 i (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 I Local Health District. 1 Job Address ,7`2_/6 CiLot SizcQ[t /"-"Led PM ,?a56 — ' Z 1�6 tC Phone`s 6 �Z.� J - Owner's Name 'd Address Contract JAddress r /License No. 729 ZZ4 PhoneG TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL i PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications ! _ r , 11 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approxi Depth 1 I Eastern Surface Seal Installed by _ Repair Work Done L3 Type of Pump H.P. State Work Done_ Y Well'Destraction_ ❑ Well Diameter Sealing Material {top 501 Depth 1 Filler Material RBelow 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADOITION l I DESTRUCTION I I (No septic system permitted if public sewer is r v available within 200 feet-1 Installation 1will serve:. Residence L Commercial_ Other Number ofrliving;units, _/_ Number of r ms s f S Character'of soil-to a depth of 3 feet:+ Water table d h" SEPTIC TANK Type/Mfg Capacity No. Compartments PKG.m-TREATMENT PLT. ❑ 1 f f "Method of-Disposal Distance to nearest: Well�� -.- Foundations =l® Pro perty,Lin� LEACHING-LINE--4 No. F� length of lines '- �® Total length/size X 21 J}' FILTER BED ❑ Distance to nearest: Well /�0 Foundation'- /0 Property Line rf� f SEEPAGE PITS Depth �~57 Siie -All N bar . ,SUMPS LlDistance to nearest: Well`T-l�Q - Foundation �Property Line w .DISPOSAL PONDS ❑ '' -.�F _4 'I hereby certify that I have prepared this application~and'that the work will be done in accordance with San Joaquin county ofdinances, state lawsder-, ana +5 rules and regulations of the San Joaquin Local Health District. ti 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, 1 shall not mp eloy ariy person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature r 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." 4r The applicant must for all re d I ctions. Complete drawing on raver e. -. Signed Title: f Date:r/ FO DEPARTMENT USE ONLY Application Accepted by Date ZI--� , Area Pit or Grout inspection by Daza Final Inspection by Additional Comments: Comments: { C'-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., f.O. Box 2409, Stk., CA 95201 `Q FEE AMOUNT DUE: AMOUNT REMITTED CK 0 RECEIVED BY DATE I PERMIT'NO. INFO CASH +.EH 13-24 IREV,1/R 5) EH 14-28 c, S 1�:31931 ' t ��