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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. } 1 C, Cts. � Job Address City t� y Lot Size PM �-' Owner's Nam Is Address W. Phone Contracto ddress 5 I License No. z Phone 5- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION LJ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER EJ DISTANCE TO NEAREST:-SEPTIC.TANK SEWER LINES DISPOSAL FLD. PROP. LINE v 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 ° -❑wDomesticl-Private-_ >❑ Gravel Pack �.D Tracy Type of Casing--- — - Specifications 'f l Pirblic"X T, t 171 Other 1-1 Delta Depih o('Grout*Seal s Type of Grout - x I I irrigation n _.Approx.'Depth I 1 Eastern Surface Seal Installed by - r Repair Work Done^ C7 Type of Pump�" -H.P: 1Nork Done_ Well Destruction ❑ _Well Diameter Sealing Material (top 501 Depth ` Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Is- Other T ' i Number of living units: Number of b rooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ` Type/Mfg _ Capacity-4-20 0 C No. Compartments PKG. TREATMENT PLT. ❑ 1 ? _i Method of Disppsal 'Distance to nearest: We11i5c_.— Foundation: _— Property-Line . .— p© LEACHING LINE No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well._ � Foundation /d Property Line �A 1> - �/ � SEEPAGE PITS 1 I Depth Size X�`7 Number.,) - - R SUMPS 7� Distance to nearest: Well/f: Foundation—�C�` Property Line zi 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 laws, an Lt rules and regulations of the San Joaquin Local Health Di§trict. `` Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which ttiis'pe`mit is issued, I shall not employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's,hiring or sub-contracting signature i 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." The applicant m t call,for a uire inspections. Complete drawing on reverse Fi -_ w V _Signed X Title: ' Date: 4,1 FOR DEPARTMENT USE ONLY Appli tion Accepted by Date- ' Area rout ntion bgy &gAPDt-° _ Final Inspection by ate Additional Comments: ! ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 Applicant - Retutn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box,2009, Stk.;CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 13Yi+ DATE PERMIT'NO. INFO a.EH 13-241REV.r/951 D uV EH 14-26