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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA „, I Telephone {209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED �� (Complete in Triplicate) QRed1V LT/�C0tln Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein s r bedd is/a�eplicataq is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulafi (sro wu5t1 Joaquin Local Health District. ills,jAv ' LCity G Aj-,) Lot Size PM < Job Address I Address S ji j'"'► Phone _ Owner's Name i r r r s Contractor Address �!N License N� Phon �" TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ r.= S _ �- DISTANCE TO NEAREST�SEPTIG TANK-. "-�. �..51"WER_LINES s -DISPOSAL FLD._ PROP. LINE.. 1, FOUNDATION ti :-`� AGRICULTURE WELL OTHER WELL PITS/SUMPS . INTENDED USE TYPE OF WELL r„=PROBLEM AREA CONSTRUCTION SPECIFICATIONS -w .. ❑ Open Bottom ❑ MantecarDia. of Wel! Excavation Dia. of Well Casing ❑ Industrial ; -A 5 Specifications "Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing — X Other aGl Delta; ', �S!6 pth of Grout Seal Type of Grout o� [`1 Public .;�� r � � *.`F� � . t I I Irrigation _.Approx. Depth I I Eastern Surface Seal installed by — Q ✓ 1 State Work H.P. Done r� Repair Work Done X, Type of Pump Well Destruction LlWell Diameter Sealing Material Itop 50'1 Depth Filler Material Malow 50'I TYPE OF SEPTIC WORK NEW INSTAL•LATION't I #REPAIR/ADDITION l l DESTRUCTION I I (No septic system pe lable thin 200 feetit`ed if public sewer is Installation will serve: Residence Commercial_' 0thef"y -4 i( Number of living units: Number of bedrooms x i k Character of soil to a depth of 3 feet: Water table depth `t= =� i Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ + 1 ," ? i Distance to nearest: well Foundation Property.Line F LEACHING LINE's "❑'*L'No. &'Length of,lines Total length/size r FILTER BED ." ❑ Distance to nearest:.. Well Foundation Property Line j SEEPAGE PITS" hl-, Depth —' Size Number - , .--w O Distande=to-nearest.'"-Weil-f._,,.� ."Foundation-;.t-� -"�.-'"ProPertll-Line S�•IMPS�- , r DISPOSAL PONDS ❑ r d that the work will be done in accordance with San Joaquin county ordinances, state la I hereby certify that I have prepared this application anws, 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 in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "1 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." I s 01) The applicant t cal or all sr spections. Complete drawing on reverse side. Signed X Title: _ Date: r R DEP ENT ONLY _ i ate � � a —�-� Application Accepted by D Pit or Grout Inspection by Date Final inspection by Da Additional Comments: S ❑ 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 CA ECEIVED BY DATE PERMIT NO. INFO 144 +•EH 13-24 1REV.i/A s EH 14-28