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r F •f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 quip C un Ordinance No.,549 for sewage or No. 1862 far well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �#�� l r City G Y. Lot Size PM W Owner's Name �� d��t Address Phone _ I , _ _ .._.,.. .� __ _ .,•..,.....-..�,,,,r,.: �.., _ - �»-„..,....««.�-�,.-.�—ate,.-.,.�.......-==�- - -- - Contractor- f Address � �x” License No.a� Phone "_.____T_YPE,0F WELL/PUMP: NEW WELL ❑ WELL'REPL'ACEMENT'❑' DESTRUCTION _❑ PUMP INSTALLATION El 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 --.Manteca- _,Dia_of Well.Excavation Dia. of Well Casing ❑ Domestic/Private. ❑ Gravel.Pack ❑ Tracy Type of.Casing Specifications FI Public t ❑ Other ,° Fl Delta Depth of Grout Seal Type of Grout _ i I Irrigation - —.Approx. Depth I i Eastern Surface Seal Installed by ' r 1 i Repair Work Done 0.: _T• e.of-Primp H.P. State Work Done_ TP Well Destruction O WeIL Diameter Sealing Material (top 50') ' r I` Depths Filler Material (Below 50'1 l ,1' TYPE OF SEPTIC WORK: NEW INSTALLATION 'REPAIR/ADDITION L I DESTRUCTION i I (No septic system permitted if public sewer is W # % available within 200 feet 1 !, Installation will serve: Residence_ Commercial_ Other t Number of living units: Number of-bedrooms Character of soil to-a depth of-3 feet_ 144 ti - -- -- - - -- -Water table depth SEPTIC TANK r �''�.p Type/Mfg �� Ar, Capacity 4 _ No. Compartments l s PKG. TREATMENT PLT. ❑ 3 Method oflspas�l Distance to nearest: Wel! Foundation SO Propert'3\ LEACHING LINE 1;l,- No. & Length of lines Total lengthlsize' _i FILTER BED ❑ DistanceL nearest: Well Foundation �i f_ Property Line------T y SEEPAGE PITS t I Depth FI Size Number SUMPS Ll Distance)to nearest: Well Foundation x 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 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 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,1 shall employ persons subject to workman's compensa- tion laws of California." { The applicant nmust call for all eq 'red inspections. Complete drawing on reverse side,.. s Signed X r"��C,J Title:_ ��7 ' Date: DEPARTMENT USE ONLY Application Accepted by Date Area y,'i i Pit or Grout Inspection by Date Final Inspection by� Date�_7 jl Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201WO r f # INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. I i i +.EH1 -21(REV. - 1/x51. AL, I - EH 114-28 (, -