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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f " 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i 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. 3 AC Job Address - - _ City *cK Lot Size io PM Owner's Name /��' � % � fw� Ho, Address 6' x 1 kT r 60'" �'. Phone 1.I Contractor—_� .., : " ; Address _ License No. Phone TYPE OF WELL/PUMP: * NEW WELL ❑ Y 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f`l Public ❑ Other I:l Delta € Depthof Grout Seal , Type of Grout _ I Irrigation _..Approx. Depth l I Eastern Surface Seal ln'sta]]ed by _ { _ O Repair Work Done ❑ Type of Pump WO State Work Dane Well Destruction ❑ Well Diameter Sealing Material Itop 501 r Depth Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION &—REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) I Installation will serve: Aesi nee Commercial— Other Number of living units: Number of bed om/s Character of soil to a de th of 3 feet: .1p _ Water table depth �® } SEPTIC TANK 'Type/Mfg CO—PA."" .Capacity/4 d - No. Compartments PKG. TREATMENT PLT. ❑ � - --1} �..- Method of Disposal Distance to nearest: Well Foundation 6 Property Line �� s - 4 i LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well p(�"�' Foundation Property Line xV SEEPAGE PITS Depth 2!C : Size _'' Number t SUMPS Ll Distance toynearest: Well Foundation Property Line ; t DISPOSAL PONDS ❑ .4 t T I ` *J6 4I 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, i shall employ persons subje t to workman's compensa- tion laws of California." ' The applica - ust all for all reZ.4~1_ nspections. Complete drawing on reverse side. Signed X "`'"^�-'Title O +A o_r Date: 1 FOR DEPARTMENT USE ONLY {� Application Accepted by Date -�-�Y1 Area 1 , or Grout Inspection by ate3�)9-Final Inspection byT� Date C Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 L7 Manteca 823-7104 ❑ Tracy 835-6385 # Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 55201FEE ! CK INFO AMOUNT DUE AMOUNT R�.EMITTED CASH RECEIVED BY DATE[y�/yy PERMIT''NO,O, y + EH 13-24(REV.I/H 5) �U: EH 11-2$ ff r