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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 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 Xdl CIS city Lot SizeA�� 0-21 PM ..,S Owner's Name , Address Phone ' Contractor's Name i4/.�/ lS License No :c 3 _ TYPE OF WELL/PUMP: Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -J PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER F1V� DISPOSAL FLD, PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK - i SEWER LINES V) l- FOUNDATION AGRICULTURE WELL 'OTHER WELLT PITS/SUMPS INTENDED-USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation CI Domestic/Private ❑"Gravel Pack EJ TracT Dia. of Well Casing t-- Y ype of Casing Specifications 1 ❑ Public ❑-Other El Delta Depth of Grout Seal EJ Irrigation Type of Grout =._.Approz.-Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dane � Well Destruction ❑ Well'"Diameter Sealing Material (top 50') r• 4;Depth,. : Filler Material (Below 501) TYPE OF SEPTIC WORK:—NEW—INSTALLATION Fr REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewelis A available within 200 feet.) Installation will serve: Residence Commercial O h'er Number of living units:,_/__,Number_of_bedrooms Character of soil to a depth of 3 feet: / SEPTIC TANK Water table depth Type/Mfg ! f. Capacity__Z2 f® No. Compartments 2- .PKG. TREATMENT PLT. ❑ r Method of Disposal L Distance to nearesWell�oundation Property Line rK's" LEACHING LINE "P"'No. & Length of lines " - Total length/size 7G� FILTER BED D Distance to nearest: Well ZVi& — Foundation_!Ca , Property Line_ LS SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS cQ,.,-_.. "_-_- - _. "" -- - - -- 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 i 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 appiicant-must-call-for•all-required-inspections.-Complete-drawing-on-reverse side 4 Signed xc Title: Date: �J FOR DEPARTMENT USE ONLY Application Accepted byo' Date"_ [Z Area Pit or Grout Inspection by Date Final Inspection by �p AllDate + Additional Comments: /11 ❑ 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 ffli UNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMW'No. EH 13-24 1REV.10/831s CAY_ EH 14-28 "!i