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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. Job Address SL31 ( City Lot Sizegv `X21 a PM f Owner's Name Address R � .l 1 �t�tJVVL� lU�lt Phone s�(Q 1 Contract r Address D11, �r9� License Plo. Z 8 �� Phone �a'S��S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. 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 i'i Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _. I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') �- Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 1. -'DESTRUCTION I 1 (No septic system permitted if public sewer is {-// available within 200 feet.) Installation will serve: Reside _ Commercial 7�Other Number of living units: Number Has^} r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg �-Capacity_l�©� No. Compartments PKG. TREATMENT PLT. ❑ I f- Methodof Disgosal Distance to nearest: Well Z On+ Foundation 10 Property Line_ ,5 LEACHING LINE � No. & Length of lines ""' Total length/size r P FILTER BED ❑ Distance to nearest: Well-100 1 Foundation--- 0 14 Property Line Vis'fi I / SEEPAGE PITS Depth C9 Size _ Humber SUMPS 0 Distance to nearest: Well 1.SD t Foundation)I Property Line S + 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, statelaws, 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." Contractors 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 applica ust call fo eq 'ed inspections. Complete drawing on reverse side. Signed X Title: Date: ARTMENT USE ONLY Application Accepted bySt Date - ati Area Pit or Grout Inspection by Data Final Inspection bzs' __ Date 124 - Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE QPE}KNIT'NO. + EN11-2gIREV.fin5r ,�.� � lj LI"O � 7