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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone 1209? 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 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 - ' "" '^ t' +� r' � City r A, 'd 4 1 ' i Lot Size 1`,� ' � �� 1 PM Owner's Namt °! b �i lY'..A )- dd ss 2;_21,7 a , +" 'f1. Phone F Y Contractor fc 1. 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 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 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ___________ I I Irrigation _.Approx. Depth 1 I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 119 REPAIWADDITION I. ) DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: __V__ Number of bedrooms 5L Character of soil to a depth of 3 feet: .-« — x- --_ s Water table depth SEPTIC TANK Lam" Type/Mfg Capacity % No. Compartments " PKG. TREATMENT PLT. ❑ Method of DispoIa] Distance to nearest: Well fi ` ^mss Foundation Property Liner LEACHING LINE No. & Length of lines '~" Total length/size FILTER BED ❑ Distance to nearest: ell Foundation N t.'2t f Property Line SEEPAGE PITS 11 Depth S + Size li -- Number SUMPS Distance to nearest: Well 2 Foundation -�C3 Property Line 1. C DISPOSAL PONDS ❑ 1 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, 1 shall not employ any person in such manner as to became 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." e� The applica 'st call for all.req ire etospecWnp.`Complete drawing on reverse side. Signed Title: €-'fit - bate: f'd —", FOR DEPA MENT USE ONLY Application Accepted by Date Area .44 Pit or Grout rInspection by Date Final Inspection by k Date Additional Comments: maw,-"sa?=4._+.p-tz^--a.._._ y-`�..rt�r,�.. 3"^ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca-"1123-7104 ❑ Tracy 835-6385 Applicant- Return all copies'to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE ASH DUE AMOUNT REMITTED A$H RECEIVED BY DATE PERMIT'NO. INFO t ♦:.'rcH 13-24 WV.rin51 .x T '�PF}...�'�. ti,,;✓'1 'J. ' .- EH 54-26