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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 'I 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 F 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 Local Health District. JobAddress CitY C� �'� Lot Size 1 # PM Owner's flame �G �' Address Phone 47,5 C Contractor �',� Address License No. phone �'i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ t DESTRUCTION ❑ ----» -.PUMP.INSTALL-ATION-❑-* SYSTEM REPAIR ❑ ""'""�-' ' OTFIER ❑" T "�""" "` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications L1 Public ❑ Other l ❑ Delta Depth of Grout Seal r T C ype of:Grout ry ❑ Irrigation —Approx. Depth ❑ EasternSurface Seal Installed by } " `'+ ' 3 i r Repair Work Dane .❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material ftop,5O'1' Depth Filler Material (Below 501. - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION El'l septic system permitted if public sewer is i availabYe within 200 feet.► ` 1 Installation will serve: Residence Commercial_ Other Number of living units: —A— Number of bedrooms 1 W } Character of soil to a depth of 3 feet: . �5 _ Water table depth r '� SEPTIC TANK LlType/Mfg _� j*. 4 f '• f v F 7 Capaatly��_� No. Compartments k PKG. TREATMENT PLT. ❑ rS/ 1 }, Method of Disposal Distance to nearest: Well" �y Foundation, �f d f! Property Line _/ 1 LEACHING LINE �. No:& Length of lines L Y ngth/size FILTER BED ry.❑ Distance to nearest: Well d�� FoundationWWI, 'Property Line n. j # SEEPAGE PITS ❑ Depth } 7 Size ' --Y 'N b' SUMPS, p Distance to.nearest: Welles Foundationt � Property Line DISPOSAL PONDS ❑ d 1 hereby certify that 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. fir .- 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 shall employ persons subject to workman's compensa- tion laws of California." I The applicant must call for all re fired inspections. Complete drawing on reverse side. �� Signed Title: `:` or Date: Z FO EPARTIMENT USE ONLY Application Accepted by � � u Date ' ' Area to Pit or Grout Inspection by Date 11 Final Inspection by - Date d v Additional Comments: t ❑ 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 CK CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.1/H 5) TT6-9LU EH 14.28