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I APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 4&4 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hot eby made to th� 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. II • Job Address L�'7 6� � -1I� k �Il City T Lot Size � � __ PM Owner's Name c-/C I7 Address Phone * fi Contractor Address G License IVa. 31 Phone TYPE OF WELL/PUMP: I NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C3 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK i�,SEWER-LINES �.._.. DISPOSAL FLD.l PROP. LINE f FOUNDATION- AGRICU LTU REWELL _—OTHER-WELL-: PITS/-SUMPS t/ INTENDED USE' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S 8 SISr Open Bottom 0 industrial.�\ ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X17 KcimesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �(� q� �- '�� Type of Grout q��. M Public f� Other ❑ Delta Depth of Grout Seal yP . I I Irrigation € —'!..Approx. Depth I I Eastern Surface Seal Installed by - i. Repair Work Done ❑ Type of Pump t -H.P. tate Work Done Well Destruction ❑ Well Diamet Sealing Materi 'i Dep Filler Mat gal (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION II REPAIR/ADDITION i 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: Number of bedrooms '6 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments _ PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation ---Property-L-ine t i' u "`LEACHING LINE ❑ No. & Length of lines / ^�7. Total length/size dl FILTER BED; ❑ Distance to nearest: Well Foundation' Property Line II ; ` SEEPAGE PITS l 1 'Depth ize ,Number f I jSUMPS 11 Distance to nearest: Well Foundation l Property Line DISPOSAL PONDS ❑ 1 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 Diltrict. � ,ti Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which.this.parmit-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,_l.shall employ persons subject to workman's compensa- tion laws of Califomi .' �i + v� _ -"` -- - - ° ' 1 The applicant must gairad inspection . plate drawing o`n reverse side. - Y � i I I An Signed X _ Title: Date: 19 FOR DEPARTMENT USE ONLY iI 7Z7Y7 - �- - - - - • Application Accepted bye _:Date «Clll Area b qL Final Inspection by Date Pit or Grout Inspection y ; v e Additional Comments: I ❑ 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. 6 INFO +.EH 13-24(REV.t/x 5) —EH 14-26 - -- -