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_ r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE,TON AVE., STOCKTON, CA Telephone (209). 466-6781 F 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 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. [Q t Job Address i G e City v G Lot Size PM t _ , . { Owner's Name C IkAddress Phone l Contractor ( G Address �G 0 License No`. [� �Phone M TYPE OF WELL/PUMP: NEW-WELL".❑ C`. -WELL REPLACEMENT ❑ DESTRUCTION ❑ 'kWP 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 ak ❑ Tracy l Type of Casing Specifications El Domestic/Private E3 Gravel � I`1 Public Cl Other' C1 Delta Depth of Grout Seal Type of Grout I I Eastern Surface Seal Installed by I 1 Irrigation _..Approie. Depth - Repair"York Done ❑ Type of Pump H.P. State Work Done N j. WellfDestruction❑ WeIIDiameter e`aling'`Maferial atop 50'1 ". Depth I '`- Filler-Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I'I 'REPAIRI'ADDITION 1 TDESTRUCTION I I iNo septic system permitted it public sewer is jt 4, '"""..'.IM available within 200 feet.) Installation +'llation will serve: Residence Commercial_ Other—"" • j Number of living units __J_ Nurrtber.of bedrooms-------- Character of soil to a depth of 3 feet: Joe,h 4E, Water table depth SEPTIC TANK W/Type/Mfg C, Capacity_- No. Compartments- PKG. TREATMENT PLT. EI Method of Disposal koDistance to nearest: Well Foundation Property Line --� LEACHING LINE V-_"No. & Length of lines �`' ) 0 _ Total length/size db FILTER BED LJ Distance to nearest: Well Foundation kj Property Line ._:..._ r SEEPAGE PITS l I Depth ' Size Number I SUMPS ❑ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ i b 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 r _ rules and regulations of the San Joaquin Local Health Di1trict. 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- tion laws of California." , The applicant must all for all r quir d inspections. Complete drawing on reverse side. I Signed X Title; i F DEPARTMENT USE ONLY /,p ?- 3 _ Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by oat-1.4— Additional Comments:- ❑ Stk 466-6781 ❑ Lodi 369.3621 El 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. INFO �.EH 13-24[REN.118 51 •T...�. I)�, g �'7 EH 1�4-26� -