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l 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 t6 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 Rgles and Regulations of the San Joaquin Local Health District. gip. Job Address //: 7atL� A /�', �/1�1 f-- Ci' r LotSizePM Owner's Nam,&a" Address I Phoned Contract Addressg} i �al,,• License NoLlo O6?_�2& _Phan I TYPE OF WELL/PUMP: !I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ y } 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% PROBLEM AREA CONSTRUCTION SPECIFICATIONS —. Q-Industrial map-Open-Bottom— --O-Manteca Dia:of-Well-Excavation---Excavation----——Dia:of"Well-Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications v ! ❑ Public ❑ Other ❑ Delta Depth of'Grout Seal Type of Grout ❑ Irrigation _Approx. Depth ❑ Eastern SurfacecSeal Installed by T f Repair Work Done ❑ Type of Pump H.P. State Work Done V \ Well Destruction ❑ Well Diameter Sealing Materia�lMtop 501 Depth f Filler Mate l (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIWADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is .r 1: available within 200 feet.) } Installation will serve: Residence -Commerciale ther Number of living units: Number of?b;dr oo ms r Character of soil to a depth of.,3 feet: Water table depth ' SEPTIC TANK Type/Mfg-. Capacity _ No. Compartments 1 PKG. TREATMENT PLT. ❑ :,l '` / Method of Disposal Z. Distance-to nearest: Well� Q_� Foundation Property Line Ii T: '. LEACHING LINE lirNo. & Length of lines -_ Total lengtbjlize_4CA — .I FILTER BED ❑ Distance to nearest: Well Foundation Property Line. SEEPAGE PITS ❑ - Depth Z,2 Size X 'Number YY^ SUMPS �' L� Distance to nearest: Well 5— Foundation__ Property Line_ �_....._- 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, 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-1 shall employ persons subject to workman's compensa- tion laws of California." The applicant rqust call for required inspections. Complete drawing on reverse side ► J Signed Title: �(• �� Date: t � FOR DEPARTMENT US _ LY Application Accepted by -% ^.' Date !" Area it or Gro Inspection by �v Date� Final Inspection by � �rzo Additio Gem ❑ Stk 466-6781 ❑ Lodi '369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to:�:Environ mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEE) CK# RECEIVED BY DATE PERMIT"NO. INFO CASH +EH 13-24(REV. /B sl EH 14-26 I �J