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r,f? APPLICATION FOR PERMIT i ` SAN JOAQUIN LOCAL HEALTH DISTRICT A/1 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete in Triplicate) t 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. [ �/� J �i 3 q D f t�]r J ,Z,, L lh �U City � nz Lot Size J C'�S PM Job Address ,,,,// �]. e_ _ .rO�1. @ jj b df 8lf S t�(f/� esS �/O e g�.>'�Im Phoney Owner's Name Address r� t Contracto !'J/�" Lo Address d �/M` ��&-License No. �� Phone ��` TYPE OF WELL/PUMP: NEW.WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK J SEWER LINES 110 ':k DISPOSAL FLD. PROP. LINE�°7o FOUNDATION AGRICULTURE WELL. OTHER WELLr PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r� ❑ Industrial .❑ Open Bottom Manteca Dia. of Well Excavation t - Dia. of,Well Casing._ :4 Domestic/Private 19 Gravel Pack :° 17rTracy Type of Casing yC Specifications Class '(`I Public ❑ Other ❑ Delta Depth of Grout Sea! Type-of.Grout- I I Ir{igation —.Approx. Depth 11 Eastern Surface Seal Installed by I,RepairWork Done •_:,L] Type of Pump H.P. State Work Done k W 1 Destruction xa Well Diameter Sealing Material (top 501 k E Depth Filler Material (Below 50 -- F _ l TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION I ] DESTRUCTION I I (No septic system permitted if public sewer is 1� available within 200 feet.) �3 I Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms 4 Character of soil to a depth of 3 feet: - Water table depth i SEPTIC TANK 11 Type/Mfg Capacity No. Compartments s PKG. TREATMENT PLT. ❑ Z Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ` ❑ Distance to nearest: Well Foundation Property Line _SEEPAGE PITS I I Depth Size Number I SUMPS L Distance to nearest: Wtf11 "" "Foundation - Property Line r DISPOSAL PONDS ❑ `■, 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 Diltrict. 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 must call for all re fired in pections. Complete drawing on avers side``. (Signed X Title: V Date: %- FO DEPARTMENT USE ONLY ;Application Accepted by Data an Area Final Inspacti b-�� I Pit or Grout Inspection by Date Additional Comments: F1Stk 466-6781 ❑ Lodi 369-3621+ ❑ Manteca 823-7104 C1 Tracy 835-6385 �! ! Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,,P.P...O..Box MO9, Stk., CA 9520 FEE AMOUNT DUE AMOUNT REMITTED CK RECEI D BY DATE PERMIT'NO. INFO CASH +.EH 113-24(REV.ria5r FH i4