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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE., STOCKTON, CA f Telephone (209) 466-6781 LN.)C� PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED , „ . .(Complete1n-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. 18.62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address _5� �5 Lot Size PM Owner's Name Ia �h_►7'_ %J 0�Address D t C�� Phone b i Contractor S le Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F}LD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ( Dia. of Well Casing j ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grbut Seal Type of Grout ❑ IrrigationI --Approx. Depth ❑ Eastern Surface Seal E Installed by I Repair Work Done' ❑ Type of Pump H.P,; 3 1 , State Work{{Done_ Well Destruction ❑ Well Diameter' Sealing Mater#l (top 50'1 1 Depth t Filler Material (Below 50') TYPE OF SEPTIC W ORK: NEW INSTALLATION ❑ REPAIR/ADDITION C1 DESTRUCTION (No 'septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence_ Commercial _Other --- -__--_ - Number of living units: Number of bedrooms' Character of soil4 to a depth of 3 feet: }li ', j0 1 IN Water table depth J-- SEPTIC TANK Type/Mg - F - Capacity No. Compartments PKG. TREATMENT PLT. ❑ „ +^ ✓' 7___+ Method of Disposal �` r Distance to nearest: Well �`^'� Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER.BED, ❑.Distance to'nearest,�Well 7=_---Foundation-R-- -Property-Line -- - ^� - - --- - SEEPAGE.PITS ❑ - Depth �-.�•r�-- ' xE Size - 4� - SUMPS �❑ ,.Distance to nearest: Well Foundation Property Line k DISPOSAL PONDS ❑ I hereby certify thai 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 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,6 such 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant -)call fo all jrequired inspec ions. Complete drawing on reverse side. f Signe �h 111 . Title: I Date: FOR DEPARTMENT USE ONLY ^ Application Accepted by Date Area Pit or Grout Inspection byDate Final Inspection by Dat 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY I.DATE PERMIT'NO. + EH 13-24(REV.1 85) v�� - -3!�^'r ('/-1 -1 „Q(/ EH 14-26 1 O 1 iO `