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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA l Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED ¢j (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 l made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �`� /� City Lot Size z. 14cte, PM Owner's Name _2l 49= M 82 Address o Phone �' Dt� � Contractor /�bllr� Address License No. Phone i TYPE OF WELL/PUMP: NEW WELL 1:3WELL REPLACEMENT LJDESTRUCTION W 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 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ SecificationsGrave! Pack ❑ Tracy Type of Casing P ("1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout -- I Irrigation _..Approx. Depth l I Eastern Surface Seal Installed by - r Repair Work Done ❑ Type of Pump H.P. State Work Do e Well Destruction ell Diameter r7:j L Sealing Maieriint'op 50'1 Depth ( - Filler Material (Below 50') D - ,' TYPE'OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is T1 available within 200 feet.] Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms 'v Character of soil to a_depth of 3 feet: I- `�- Water table depth r SEPTIC TANK. Q Type/Mfg Capacity No. Compartments V1 PKG. TREATMENT PLT'D Method of Disposal k r Distance to nearest: Well Foundation Property Line ` i " f J s LEACHING LINE ~❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS IV (I Distancerto nearest: Well Foundation Property Line + DISPOSAL PONDS ❑ 'I ---- I I hereby certify that I have prepared this application and that the woPk will be done in accordance with San Joaquin county ordinances, state laws, and ' 11111 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 6 employ any person in such manner as,to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature F 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." o The applicant t call or all re ed i pectines. Complete drawing on reverse side. o t Title: (5i ase' �,4�t�'-3� aEf i(L$ate: I'2b " R Signed X 11 OR DEPARTMENT USE ONLY i. frF✓ ` � Date l Application Accepted by Area Pit or Grout Inspection��byy Dale __� inai In act i b Data Additional Comments: Y 01 �' "� z i ❑ Stk 466-6781 ❑ Lodi 369-3621 LrManteca -7104 ❑ Tracy 835-&385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 L FEE AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE PERMIT'NO. INFO p LTC) I))) F +.EHt3 -241REV.i,as1 ,, °T.l! 3�. I— b-71) p O 9� �f r EH 14-M