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of 'l '/ ,... APPLICATION FOR PERMIT VVW SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cornplete 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 ref 3 't J I Q S S'Err RFy" City ErGt G Lot Size PM /� Owner'slVame��(/{e�'1 � � 11 l�r.a' r� �`�r Address 0°��-'�`fr F�=i�" Phone 3 Ct Contractor J` 1 T _Address License No. 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 INTENDED USE TYPE OF WELL r""'PROBL'EM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r D Domestic/Private Ll Gravel Pack El Tracy Type of Casing Specifications FI Public f-I Other f Cl DeltaF Depth of Grout Seal Type of Grout I I Irrigation ____,Approx..Depth I I Eastern Surface Seal Installed by _ III Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 ! — TYPE OF SEPTIC WORK: NEW INSTALLATION IIQ REPAIR/ADDITION I I DESTRUCTION I k {No-septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence Commercial_ Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK i Type/Mfg hirp�% =""Capacity 210 r` I No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 7 t Distance to nearest: Well p 5 Foundation ,� Property Line 120' q LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation, U!0 Property Line_-L 1Z7J4__ SEEPAGE PITS 11 Depth Size Number SUMPS C Distance to nearest: Well Foundation .Property Line DISPOSAL PONDS ❑ � r -4 I hereby certify that I have prepared this application and that the workMwili be done in accordance with San Joaquin county ordinances, state laws, 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 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. f Signed X /h� lJOX 0?.�2�- Title: C4/4 4 0— Date: arc' �1 1 . IF FOR DEPARTMENT USE ONLY Q2 Application Accepted by �4�` Date ✓ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca -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 I AMOUNT DUE AMOUNT REMITTED ASN RECEIVED BY DATE PERMIT-NO. INFO r� . EH 19-241REV.t/A57 �U f ` EH 14-28 t