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APPLICATION FOR PERMIT a . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,I STOCKTON, CA Telephone'(Z09) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {., (Complete in'Triplicate) I 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 I 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 :,.� . d7� �C-Gold Local Health District. "-07 .0 ,,, city S .J Lot Size 7a�r 7. ' _ PM Job Address r, € ! 4S C A l2 'C�fl S Address 5 A"rr�`� - - Phone - r Owner's Name Contractor W Address -� �...N•--r�lt 2�'IAa W License.No. yS-2.7t Phone hs 3 Irn 'NEW WELL ❑�� WELL REPLACEMENT ❑ DESTROCTION E3TYPE OF WELL/PUMP.: PUMP INSTALLATION ❑ . SYSTEM REPAIR ❑ OTHER CI DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE T"" '"'�;;f: `FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS dIN ENIJEQ-USE4--6 -r,,TYPE-OF-W.EL-L--- PROS L-EM-AREA+-GONSTRUCTiON SPECIFICATIONS'^- ❑ Industrial 0 Open Bottom i 1 Manteca El Dia. of Well Excavation Dia. of Well Casing Domestic%PriType of Casing tt: Specifications , vote"'""'"'O Gravel Pack © Tracy 1:1 Public ' `C3 Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation tea, ---Approx. Depth O Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction HI Well Diameter Sealing Material Itop 50'} I w'f Deptih-, Filler Material {Below 501 _ { TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �.> available within 200 feet.) w Installation will se rv(4 Residence—✓� Commercial Other Number of living units:� Number of bedrooms ; Water table depth ' I Character of soil to a depth of 3 feet: , Capacity ,No. Compartments SEPTIC TANK 21-1,Type/Mfg � � -Method of Disposal PKG. TREATMENT PLT. ❑ i +n ' Distance to nearest: Well— — Foundation 1 O '-- ,Prperty Line s~ LEACHING LINE No. &Length of lines Total length/size rX AJ A Foundation Property Line, Q FILTER BED 11 Distance to nearest: Well _ - 10 ='� Size �' ,x + Number SEEPAGE PITS` VDeisptance fi i SUMPS _ to ne.aresi: w. 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 lavas,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: "I certify that in the performance of the work for which this permit is issued, I shalf'employ persons subject to workman's compensa- tion laws of California." _ 4 The applicant must;call for all re uired inspection Complete drawing on reverse side. - - Date: Signed )( FOR DEPARTMENT USE ONLY ' "-- z Area 016 Application Accepted b Date f4_ Pit or Grout Inspection by r Dat ' Final Inspection Date ZT/A — ' Additional Comments: Ej Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104' ❑ Tracy 835-6M ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009;-Stk., CA 95201 4-,N FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT ND. INFO CASHT _` + EH 13-241REV.t?8_M l0-�13lo w EH 1426 "r