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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 Rules and Regulations of the San Joaquin Local Health District. / T Stmt Job Address .r ( Lot Size r � M Owner's Name . Address f J 19 01 o � Contractor Address Y,,:��.nse No. Phone 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 INTENDED USE TYPE OF WELL PROBLEM AREA —CONSTRUCTION SPECIFICATIONS .t\1 EJ Industrial © Open Bottom 1-1MantecaDia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r " M Public n Other Cl Delta Depth of Grout Seal Type of Grout _ 1 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ "Well Destruction ❑ Well Diameter Sealing Materia! (top 50'I - — Depth Filler Material (Below 501 4 TYPE OF SEPTIC WORK: NEW INSTALLATION 1,V REPAIR/ADDITION l 1;- DESTRUCTION I 1 (No septic system permitted if public sewer is \ x ] available within 200 feet.) Installation will serve: Residence_L Commercial Other " Number of living units: _L_ Number of bedrooms ' Character of soil to a depth of 3 feet: �' Water table depth SEPTIC TANK ❑ Type/Mfg '— _Capacity No. Compartments i WG. TREATMENT PLT. ❑ i f Method of Disposal, Distance to nearest: Well fi —� Foundation Property Line f ot %LEACHING LINE � No. & Length of lines V, — M1 � Tgtal length/size FILTER BED ❑ Distance to nearest: Well `� Foundations Property Line SEEPAGE PITS I I Depth l x /0 x to size - Number UMP El Distance to nearest: Well 1604 Foundation Property Line 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 District..1� �,:, . Home owner or licensed agent's signature certifies the-followin : "I certify that in the performance of the work for which this permit is issued, I shall not tires employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature 4101-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." I The appiican ust 11 for all re "ed inspections. Complete drawing on rjgqrse side. / 1 r lJ�j Signed X Title: � �✓ ___-_ Date: FOR DEPARTMENT USE ONLY Cr Applica' n Accepted by Date) A ea 7— .___46ut Ins ction by ate Final Inspection by Da Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Health Pefmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK I RECHVED BY INFO CASH DATE PERMIT'NO. C g I (,PE . EH13-241AEV.i Ili 5117 EH 14.26 ] I!!! (1