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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 3 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1' 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 Local Health District. Job Address �0[X£Y/ �~'+' ��1 /'�G City / ICJ Lot Size_t=2 /4eA!t, PM Owner's Nam//e004) _vC z�� Address —_ Phone Contractor t- ri Address License No.Y4C.3o205� Phone 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 PITS/SUMPS `, I INTENDED USE TYPE OF WELL PROBLEM AREA- CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑ Manteca -.Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑'Gravel,Pack ❑ Tracy Type of Casing Specifications ❑ Public r - - ❑-Other - D'DeltaZ' Depth of Grout Seal 'Type of Grout t ❑ Irrigation --Approx. Depth ❑ Eastern) Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Wotk Dgne Well Destruction ❑ Well Diameter -_--Sealing Material'{top 50'I � Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is . �. .r '---�_avdilatile within 200 feet.I , Installation will serve: Residence_ Commercial Other t Number of living units: �� Number rof bedrooms _ ---"` Character of soil to a depth of 3 feet T l Water table depth �� s SEPTIC TANKS Ca, Y�Type/Mfg �� G�9 4% ,0 Q44'Capacity /. a�D No. Compartments PKG.,,TREATMENT PLT. ❑ t J r Method of Disposal' Distance to I arest: Welly Z56 Foundation.—/0— Property Line /U , LEACHING LINE Pt—_No. & Length of lines 24 Total length/size l FILTER BED ❑ Distance to nearest: Well Foundation Property Line I t SEEPAGE PITS J-6- Depth Size v�rd lNumber SUMPS ❑ Distance to nearest: Well_ /5-0 Foundation lf7 Property Line ld DISPOSAL/PONDS/ ❑ I hereby certify that,l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulation`s 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 knot employ ariy 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 lawsoof!``California." The applicar t yduR call f r all required inspections.-Comp e d rrwing on reverse side. } X f -- _._ Date: /v� FFR DEPA TMENT USE ONLY # Application Accepted by Jf ff-r Data �e7 �� Area Pit or Grout Inspection by Dater- Final Inspectim by, Date Additional Comments: Cl Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - O 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, s' CASH RECEIVED BY DATE /P+E�RMITNO. + EH13-24 f REV.1/85) Or �•y y'�/ EH 1428