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APPLICATION FO'R PERMIT - ray SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 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.l •. Job Address r o_ ��` .�F�t L�'i7lc �, e� City Lot Size PM Owner's Name., Address &'Y7/fi�� (.t�t��ace,`4�L Phone t Contracto is l! Address-& k V7 O�-�c- License No. zz Z2-zl Phone 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO !NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS Q INTENDED USE TYPE OF WELL PROBLE�ARECONSTRUCTION SPECIFICATIONS❑ Industrial ❑ Open Bottom ❑ Manta. of Well Excavation Dia. of Well Casing �. ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications I'1 Public Cl Other fl Delta Depth of Grout Seal Type of Grout I Irrigation �.-App . Depth I I Eastern ""Surface SealInstalledby Repair Work Done ❑ �W.11. of Pump H.P. State Work Done _ Well Destruction Diameter Sealing Material (top 50'1Deph Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence'141 Commercial_ Other Number of living units: I Number of bedrooms f Character of soil to a depth of 3 feet: yr P Water table depth SEPTIC TANK 0�T e/Mf 4441 Type/Mfg g Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal � Fo Distance to nearest: Well 7' undation �� Property Line� LEACHING LINE iX No. & Length of lines 40 Total length/size FILTER BED ❑ Distance to nearest: Well ZG oundation w Property Line SEEPAGE PITS i Depth Size �� Number SUMPS Cl Distance to nearest: Well [ f=oundation1 c Property Line DISPOSAL PONDS El ! r 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 Di§trict. Home owner or licensed agent's signature certifies the following: "I certify that in the pili ormarice 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 ra11 for all required ' ctions. Complete drawing on reverse side.. - v Signed ( Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date r- Area .-Pit or Grout Inspection by Date Final Inspection by_�C�if� - - bate Additional Comments: 0oa d oW E,e a ❑ Stk 466-6781; ❑ Lodi 369-3621 I❑ Manteca 823-7104 ❑ Tray 5-638 Applicant- Return all copies to: Environmental.Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AM�O(U�NT DUE AMOUNT REMITTED CK CASH RECEIVED 8Y DATE PERMIT'NO. a EH 13-24 1REV.I/0S 5) /h y�f EH 14-26 ✓ V /�