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APPLICATION FOR PERMIT SAN JOAQUIN L'OCAL'HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA _ Telephone {209} 466-6* PERMIT EXPIRES•) YEAR"FROM DATE ISSUED f' 70' • ` (Complete in Triplicate') Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thework 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. 4! ''/�' x.-� .. S! - ; ' � •S:.i; �r t.�a3 >,r'`._ 1�" 3 . _ .�� v- - +..F '�. y; e , r:_ J: 9..•• . Job Address Gty S C v '' �Lt Size ``v PM Owner's Name CO 5& - Address Phone Contractor Address ?o l`f1 ,_,_License nOa�Dc - 1Phone i 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j !{ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP t LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS R INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca 1a'O,�,a Dia. of Well Excavation Dia. of Well Casing CEJ ❑ Domestic/Private C7 Gravel Pack D Tracy.. r`•v Type of Casing Specifications I] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ' ,:T ' ❑ Irrigation _ 4pprox. Depth ❑ Eastern Surface Seal Installed by j Repair Work Done ❑ Type of Pump H.P. State Work Done_ ' 909 Well Destruction ❑ Well Diameter i Sealing Materril (top `` Depth } ' Filler MatePl: (Below 50" r t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ '.REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.)! r {, �Installation.wi11 serve: Residence_t Commercial,— Other j FNumber of living units: T Number of bedroo ' T `�'`i'° -• _+= ..�,_... ,. Character of soil to a depth of 3 feet: t/ Water table depth SEPTIC TANK iV T e/Mfg-,+ # Capacity Type/Mfg g p nY �� No. Compartments + PKG. TREATMENT PLT. ❑ 11 .°' =' y ) Method of Disposal: Distance to nearest: Well y zFoundat on VProperty tine Ory LEACHING LINE ° No. & Length of lines �"'yYJ'"' LTotal length/sizer FILTER BED C1Distance to nearest: Well AEQFoundation Property Line SEEPAGE PITS ❑ Depth �r1 r Size{ +' Number + SUMPS g Distance to nearest: Well f�Foundation Prpperty Line i DISPOSAL PONDS F1 "f \ { € 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 1 rules and regulations of the San Joaquin Local Health District. ] " .+r .'. Home owner or licensed agent's signature certifies•the'fallowin I cei�f' tfiat in the performance of the work.for which this permit is issued, I shall not 9, 9 9:"" �Y pe employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring orsub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subjeef to workman's compensa- _ orf-laws-df.Cal4ornl<" j .;_ s ,� The applicant must call for re inspeci`tians" Complete drawing on reverse sid' d Si ned X�� Titie FOR DEPARTMENT USE ONLY } y Application Accepted by = Date Area Pit or Grout Inspection by Date - Final Inspection by �• i Data Additional Comments: " ❑ Stk 466-6781 ❑ Lodi 369-3621 .❑ Manteca 623-7104 ❑ Tracy 845-63B5 Applicant- Return all copies to: Environmental Health Permit/Services 1601-E. Hazelton Ave., P.O. Box 009, Stk., CA 95201 FEE AMOUNT DUE, AhhQlJNT pEM{TTED CK RECEIVED BY DATE PERMIT N0. NFO" CASH_ - } - '+ EH 13-20REV.1/.051 t EH 1426