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t E APPLICATION FOR PERMIT SAN JOAO,UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 g'made in compliance with San Joaquin County Ordinance No.549 for sewage or No_ 1862 for well Ipump and the Rules and Regulations of the San Joaquin Local Health District. ,. Job Address o t 1 o5e�� City 4 Lot Size PM I %S Address �� C7 ��'�� Phone ) Owner's Name " Contractor &I � Address C a �3 License No. d Phone �- TYPE OF WELL/PUMP: N WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 11SYSTEM REPAIR 11 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f Af 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. if Well Casing O Domestic/Private ❑ GravehPack ❑ Tracy Type of Casing Specifications -❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 0 " ❑ Irrigation -L--Approx. Depth ❑ Eastern Surface Seal Installed by ,Repair Work Done 0- Type of Pump H.P. State Work Done d VNI Destruction ❑ Well Diameter Sealing Material (top 50'} Depth .41 Filler Material (Below 501 --TYPE OF SEPT -WORK:�N4 W INSTALLATION ❑ REPAIR/ADD ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is {( ; i available within 200 feet.) .A. kj i ' - Installatidn will serve: Residence Commercial Other I Number of living units: _ Number of bedrooms m ~ Water table depth Character of soil.to a depth of 3 feet: 09 �- .Y ' SEPTIC TANK 4u LAY- 1 ype/Mtg apacity—lam— No. Compartments {� PKG. TREATMENT+FLT. E] :-- - iNteThod of Disposal 1 s0 7"_ Foundation� Property Line / l - Distance to nearest: Well��_ To — LEACHING LINE C��IVo. &Length of lines �;? - �� - Total length/size11 U FILTER BED ❑j Distance to nearest: Well__!� �_ Foundation 1 — Property Line SEEPAGE PITS Dept �•'� -Size—! Number �DZ SUMPS ❑ Distance to nearest, .Well Foundation_ f Q Property Line 5` DISPOSAL PONDS ❑ 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, fy that in the performance of the work for which this permit is issued, 1 shall not Home owner or licensed agent's signature certifies the following: "I certi . employ any_Mrson in suc_h-_manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature �. certifies the following:"1 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." I The applicant my0all Ar all re iced inspections. Complete drawing on reverse side. 5i ned I Title:f��ll/y Date: g F DEEARTMENT USE ONLY _f. - A lication Accepted by Date Area P'Et r Grout Inspection by Date Fe Final pection by Date Additional Comments:---- --- - Y ~ ❑ Stk 466-6781 "❑ Lodi 369-3621 ❑ Ment-'ca '823-7104 ❑ Tracy 835.6365 Applicant-.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. INFO CASH 't. ,. +EH 13-24(REV.1/815) "� O EH 14-28 _ 4 -