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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA -Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED ti, .. (Complete.in 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �r uL City Lot Size PM Owner's Name Address__ _62067,_BC Th1J. � Phone ` Contractor �. �Addres x ! -TO License.No, Phone. TYPE OF WELL/PUMP:J- I ` .NEW WELL ❑1 _.i WELL REPLACEMENT O DESTRUCTION ❑ ° Ali ,.flt1' � t' s INSTALLATION ❑ c 'SYSTEM REPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER�bNESbl5POSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER-.WELL PITS/SUMPS k -INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTROCTIONiSPECIFICATIONS ❑ Industrial I ❑ Open Bottom 7::�❑ Manteca: �-' Dia. of Well Excavation, ' Dia. of Well Casing ❑Domestic/Private ❑ Gravel Pack O-Tracy, Type ofECasing I I t - tla Specifications O Public ❑ Other�1` ,.. ❑ Deltas Depth of'Grout Seal I V Type of Grout ❑-Irrigation^ ---Approx. Depth ❑ Eastern i , f � _ , P Surface=Seal Installed by It Repair Workft7one ❑ Type of•Pump H.P. - t-StatetWork Done w� • -J Well Destruction ❑- Well Diameter Sealing Material Itop 50') Depth Finer Material (Below 501 _ r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (]:� STRUCTION ❑i(Ne septic system permitted if public sewer is 41 "F,-'-�- "!available within 200 feet.) Installation will sere: Residence Commercial_ Other t i Number of-living units: Number of bedrooms t Character o}soil to a depth.of..3.feet:___ _ - - Water table-depth SEPTIC TANK, 11�4ype/Mfg Capacity_1D-- DD e No. Compartments I PKG. TREASST�MENT'PLT. ❑ Method of Disposal ` Distance to nearest: Well Foundation_,30 _ Property Line _5 1 F__ ,�1 BEACHING-LINE r,'.. UL--Ko. & Length of lines Total lengthlsize i JF ILER BED t ❑+ Distance to nearest: Well Foundation Property Line SEEPAGE PIT§__—'"Z�-Depth 01.�� -Size Number I SUMPS LJ€ Distance to nearest: Well- 4M Foundation Property Line DISPOSAL PONDS 13. 1 Ihereby certify that I have prepared this application,and that the work will be done in accordance with San Joaquin county ordinances, state laws, and Q ` rules and regulations of the San Joaquin Local Health District..-' i Home owner or licensed agent's signature certifies the following"I certify that in the performance of thelwork 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:"t certify that in the performance of the work for which this permit is issued, I shall employ ploy persons subject to workman's compensa- tion j la f California." . The applicant st all for al req ed ins ction Co late drawing on reverse side. r"� r Signed Title: ! Date: FOR DEPARTMENT USE ONLY r Application Accepted by Date U� , �t •I Area Pit ornGrout Inspection by Final Inspection by Date Additional Comments: --------------------------------------- ❑ Stk 466-6781 ❑ Lodi n 369-3621 .❑ Manteca .flb-7104.i. '.�i] Tracy, -8355-6385 1 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 CK RECEIVED BY DATE PERhA1T NO. INFO pPER r + EH 1428fREV.s/n51