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4-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 County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 1 City A_L� Lot Size PM Owner's Name Address ) Phone Contract j Address L/• L Jl (o � License No,�� Ph... TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE- ----_TY-PE.OF WELL. ..-- PROBLEM AREA .CONST.AU.CTION_SP-ECIFI.CA.T.IONS__. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public ❑ Other Cl Delta Depth of Grout Seal ' Type of Grout I I Irrigation _Approx. Depth I I Eastern� Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth t=iller Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION IK REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted it public sewer is available within 200 feet.) installation will serve: Residence Commercial Other'- Number ther'Number of living-units: _/__ Number b to ms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK P' Type/Mfg Capacity 6 0 No. Compartments PKG. TREATMENT PLT. ❑ - f r Method of Dilsposal Distance to nearest:' Well Foundation 10 Property Line LS r t r LEACHING LINE �1�No. & Length of lines — —Total-1 ngth/size b X FILTER BED ❑ Distance to nearest: Well_�O Foundation IOr Property Line .5;_� SEEPAGE PITS I*Depth sY Sixe 642 Number SUMPS Ll Distance to nearest: Well 1_0(51.__ Foundation -- eft! Property Line Z5 DISPOSAL PONDS Cl 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m call for al quirftd inspections. Complete drawing on reverses e. Signed X Title: + Date: I TMENT USE ONLY Application Accepted by w Date 3-1 4m Area Pit or Grout Inspection by Date Final Inspection by Date ! � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-MS Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 �)I AMOUNT DUE AMOUNT REMITTED C KHRECEIVED BY DATE PERMIT'NO. /(} rf`+ EH 13-24(REV(tINFO 7f6 t"a EH 14-26 ��11 ff//1111