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APPLICATION FOR PERMIT, SAN JOAQUIN LOCAL-HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON', CA v I1 Fns I Telephone (209) 466-67$1 Q n PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVJRM1T ENTAL HEALT!j c,�•M [. e—go-t f (Complete in Triplicate) /SERVICES 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/puma-and the Rules and Regulations of the San Joaquin Local Health District. t f Lip J ' Job Address [� City !�Q Lot Size PM r" ��' � Owner's Name'" �}4ddress �G+ d _ Phone Contractor ,_ Address License IVa. -- Phone C TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. _ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 4. PITS/SUMPS INTENDED USE TYPE OF ¢WELL PR08f_EM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Ofpen-80ttom^F ❑ Manteca Dia- of Well Excavation ' Dia. of Well Casing Jd Domestic/Private -FIGravel Pack L - ❑ Tracy - _ Type of Casing Specifications I'1 Public f_1 Other Cl Delta t Depth of Grout Seal Type of Grout- 1-1 rout 1.1 Irrigation __Approx. Depth I Eastern Surface Sedl Installed by,,— Type Done Type of Pump ''Sl M.P. i State Work Done Wel! Destruction ❑ Well Diameter Sealing Material [top 501 I Depth f A r Filler Material l9elow 501 - I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence f Commercial .— Other .rs Number of living units: Number of bedrooms- - r; Cfiaracter of soil to a depth of 3 feet:' w Water table depth SEPTIC TANK ❑ Type/Mfgj Capacity No. Compartments PKG. TREATMENT PLT`❑ f .� "YIN Method of Disposal _ 1 `• Distance to nearest: Well Foundation Property Line ` .Total len th/.size ' LEACHING LINE�,rCI,..-Na. &-Length of.lines-------- � 9 `. FILTER BED ❑ Distance to nearest Well Foundation Property Line i SEEPAGE PITS I I Depth s a Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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, state laws, and rules and regulations of the San Joaquin Local Health D3trict. l 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 subject to workman's compensa- 711 tion laws of California." ;I The nt mus call for all fired i ction Complete drawing on79" side. Signed X Title: Date: i F EPARTMENT USE ONLY i L Application Accepted by Date ea Area Pit or Grout Inspection by Date Final Inspection by h 1 �Date r �G i 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 AMOUNT DUE } AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. l INFO CASH + EH 13,241REV.)/H5) �� O� '�s �,^.�qz C) f