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A APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 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 r — City Lot Size Z/,9/v 6w� PM `J �7�;?0 Owner's Nam Address 5 (j Phone CC Contract Address License no��S7'Z(e F'hone 36 S)—J`0S TYPE OF WELL/PUMP: NEW WELL ❑ i WELL REPLACEMENT ❑ DESTRUCTION ❑ 0 PUMP,INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i u:" a ti REST: SEPTIC TANK SEWER LINES DISPOSAL FLO. DISTANCE TO NEAPROP. LINE M FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 141 INTENDED USE TYPE OF WELL PROBLEM AR A` CONSTRUCTION SPECIFICATIONS v ❑ Industrial ❑:Open Bottom ElManteca;—4) Dia. of Well Excavation ' ' r Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ��fL y — Specifications I FJ Public f Other 171 Delta Depth of Grout Seal; Type of Grout I 1 Irrigation _Approx. Depth I I Eastern . Surface Seal Instellb-d byr Repair Work Done LJType of Pump H,P� — State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION IN G REPAI ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other` t Number of living units: —1— Number of drooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ ' Type/Mfg / "� Capacity No.,Compartments i PKG. TREATMENT PLT..❑,: Method of Disposal� ", &-F Distance to nearest:# Well r f Foundation t Property Line llvt� t r LEACHING LINE I No. & Length of lines_{ Total length/size FILTER BED ❑ Distance to nearest: Well Fundation Property Line (5 ._ SEEPAGE PITS I-) Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation I% { Property Line DISPOSAL PONDS ❑" I 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 became subject to.wsorkman_ compensation laws of California."Cpntractor'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 California." The applicant st call for eq 'red inspec . omplete drawing on r inspections.CeviFr _ Signed X `Title: �1 Date:A297 FOR DEPARTMENT USE ONLY Application Accepted by Date Area 2—, on rI Date Final inspection by Date /� Pit or Grout Inspection by Additional Comments:, Cl 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 I FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO J� ' + EH 13-24 it1EV.l i H s; EH 1428 0 L