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- APPLICATION FOR+PERMIT ° ,0i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE„ STOCKTON, CA Y .t Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 '�' „i 4 c, 4u {�� City � � Lot Size PM Owners Name — U *A0-5! _ _ Address Phone Y�Contractor x_Gft' w�Address ' .__0 0 '�.,-�; l.i`y'�ens-fVo-^----- . .,�..-•----•- - ,•�---..----.�r Ilfs� hone l I ___,,,,^.TYP.E-OF WELL/PUMP.: , � Al EW-V11ELLJ❑__,,,,WELL-REPLACEMENT ❑_r= DESTRUCTION El _ PUMP INSTALLATION C] SYSTEM REPAIR ❑ � iOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL r PITS/SUMPS t INTENDED USL TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i °❑ Ca Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well sing ❑ Domestic/Private L} Gravel Pack EI Tracy Type of Casing Specifications k � ('1 Public Ci Other 11 Delta Depth of Grout Seal i Type of Grout _J_� �s i I Irrigation t J --Approx. I ] Eastern Surface Seal Installed by r t _ Repair Work Done ❑ Type of Pump H.P. State Work Done d Well Destruction ❑ Well Diameter Sealing Material (top 50') i Depth Filler Material (Below 50'] � # "'k TYPE OF SEPTIC WORK: -NEW INSTALLATION W REPAIR/ADDITION I 1 DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other i Number of living units: -__ — Number of bed ooms Character of soil to a depth 13 feet: G Water table depth' 'SEPTIC TANK llypelMfg L t'1G "CapacityA_ No. Compartments -PKG. TREATMENT PLT. ❑i." Method,of Disposal I x Distance to nearest: Well} O Foundation D_0- Property Line !��Lo LEACHING LINE , No.`& Le gth of ines Toal length/size FILTER BED ❑ . Distance to nearest, Well Fundation r - oPropertyLine 51 -- SEEPAGE PITS (1 "Depf'h: f / Number { ��`� = Size �i I SUMPS l7f�',,stance to nearest: Well Foundation_ _ Property Line DISPOSAL PONDS Cl 4n. I hereby certify that i have prepared this applic_a'. ar 4-15at the work will be done in accordance withanJoaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. f .Home owner or licensed ageriYs signature certifies the following: "I certify that in the performance of,fhe work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation taws of.California." Contractors hiring or sub-contracting signature certifies the following: "I Certify that in the performance of the a work for which.this permit is issued, I shall employ persons subject to workman's compensa- tion,laws of-California." A' The applicant must call for all �_ -p ections. Complete drawing on reverse side.. } Signed X } r f _ Tide: Date: F PARTMENT USE-ONLII 410 t 'Application Accepted by _ '- —�-= Date Area Pit or Grout Inspection by Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmantal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE.INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT ND.- ' CASH, -- - + EH13-24(REV.tins) XX 11—f,7EH 11-29