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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT `I 'TON ON AVE., STOCKTON, CA 1641 E. HAZE Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 Rules and Regulations of the San Joaquin Local Health District. Job Address �� +'*� �� City Lot Size Owner's Name ,ti �� r1�- Address Phone C L= No. Phone _Contractor��1...��L�. _Address 5 � License _ 51 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS iNITENDED USE TYPE OF WELL? PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ( ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack: © Tracy Type of Casing Specifications * Public ❑ Other f1 Delta Depth of Grout Seal Type of Grout I I Irr�gation Approx. Depth I I Eastern .:.Surface-Seal installed-by-. - Repair Work Done ❑ Type of Pump H.P. t State Work Done c Wel Destruction ❑ Well Diameter Sealing Material (top 50,'1 s i a. Depth L$ Filler Maierial (Below 501 TYPE OFSEPTICWORK: NEW INSTALLATION (.I REPAIR/ADDITION ESTRUCTION l 1,(No septic system permitted if public sewer is g r available within 200 feet.) Installation Ml serve: Residence 'Commercial Other-, x Number of living units: /9.. Number of bedrooms _ Character of soil to a depth sof 3 feet: A } —Water table depth i „�� 1 i SEPTIC TANK ElType/Mfg J E, Capacity�l.-ate_ No:Compartments PKG: TREATMENT PLT. CI hl P4 L L o W cr'-Gt1 Method of Disposal ' Distance to nearest: Well Foundation_1-.ice_..— Property line LEACHING LINE E+--Ro. & Length of lines d Total length/size= FILTER BED ❑ Distance to nearest: WeII _ — Foundation. F'raperty time 's c rSEEPfAGE PITS I I. Deph t - 5ize� T� I Number SUMPS Ll Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ �"l'a' !1''3 I hereby certify that I have prepared this application and that the work will be done iri accordance with San Joaquin county ordinances, state laws, and . rules`and regulations of the San Joaquin Local Health Di§trict. Horne 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." Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this pernnit is issued,I shall employ persons subject to workman's compensa- c-tionf California." l The'applica t ust all or a requ d in ctio s Co tete drawingreverse icle. I P a. O Sign Title: _ Date: _ O 7 FOR DEPARTMENT UFO:- ONLY i. �. �Z^ Application Accepted by �.r�1�� __r� /t/ �� __ — Pate Area Pu oIIr Grout Inspection bye' Date Final lilspection by Date C7 ` Additional Comments: ❑ Sftk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 1,"rac}a 835-6385 Appicant- Return all copies to: Environmental Health Permit/Services 1601 E. H azeltt3n Ave., P.O. Box2009, Stk., CA 95201 6 I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. III NF0 / I�sa,f1/�1 CASH +.EM 1s-241REv.I/„B) �O r 01 ! 1L') - O {� EH 14-26 . i1 v