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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 Ryles and Regulations of the San Joaquin Local Health District. Job Address — 2 ( r� City`s t Size /� ��CS PM Owner's Name' t ftL Address Phone kD*I _ _7_ - Contractor C/ISD�L l]it �Address /T��'11Q License No. J+� �. Phone TYPE OF NEW WELL ❑ °WELIL.REPLACEMENT ❑ DESTRUCTIONS❑ PUMP INSTALLATION ❑ SYSTEM REPAIR':❑ OTHER ❑ •w-DISTANCE TO !NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE' FOUNDATION AGRICULTURE WELL ,r' 't OTHER WELL PITS/SUMPS; ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �.r ❑ Industrial E) Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casingm `- ❑ Domkic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta -tt Depth of Grout Seal r Type of Grout {, > - `i ❑ Irrigaion _.-. Approx. Depth ❑'Eastern, Surface Seal Installed by ' "�` + Repair Work Done ❑ Type of Pump H.P. State Work Done ! Well Destruction ❑ Well Diameter Sealing Material [top 50') § Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION A REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is er available within 200 feet.) Installation will serve: Residence-A Commercial_ Other r Number of living units:___._._.. Number of be rooms Character of soil to a depth of 3 feet: -C�,", Water table depth ? SEPTIC TANK '�' -% Type/Mfg Rte- +��C1' Capacity_ / �� No. Compartments PKG. TREATMENT PLT. ❑�' t'.{j 1Vlethod of i posal 0 Foundation Property Line/0 } t Distance to nearest: Wella LEACHING LINE .No-&-Length of lines-- ► '- "" „� �' '"'"� "Tatal"lengthh/size r I FILTER BED ❑` Distance to nearest! Well 149-0--L11-Foundation Property Liner✓�� "r" t SEEPAGE PITS ❑ "'Depth Size Number } SUMPS ` � Distance to nearest' Well Foundatio 0 4 Prop r4 Line Q� � {! DISPOSAL PONDS ❑ �r I hereby certify that I have prepared this application and that the work will.be done in accordahce,with San Joaquin county ordinances, state laws, and rules arid•reguiations of the San Joaquin Local Health District. ?Home owner or lic`enQ 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 lav�rs.of California." Contrl3ctor's.hiring o�sub-contracting signature certifies the followin 'I,certify that-thatperformance of the work for which this permit Is,issued-f-shall employ persons subieot to workman's compensa- tion lawI 'of Califor a." The applicant m t c for all req fired 1 ispecmete drawing on reverse side.'.. Signed Title:w Date: f FOR DEPORTMENT USE ONLY Application.Accepted by Date i, r r Area O Pit or Grout Inspection by y4 Date --. Final Inspection by Date F ' ti►� A>v U►-dc� dv� 1 wl �' �o►,-y,-�,-Tb aE.�Jl yr�� Cl No v+ 1,e fwt et Additional Comments: ! ( ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I F .41 �# i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O,'Box 200e,.Stk., CA 95201 i FEE _ EAMOUNT DUE AMOUNT REMITTED - - CK# , . - RECEIVED BY g-T ••- DATE INFO" CASH I !4 EH 13-24(REV.t/95)EH 14.26 t