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APPLICATION FOR PERMIT Y' 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 t4i San Joaquin Local Health Di thct 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. a f 1 Job Address r '. - r � �F � City � �p/J�`'47�ot Size PM , Owner's fVame �M Address,; -A .!��_ �! �'.��-.c�fe-� Phone Contractor 16,,_ /~C/L 6(SJ2,Address d �� License No.:O'�l -.Phone s TYPE OF WELL/PUMNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 71 SYSTEM REPAIR+© OTHER ❑ DISTANCE TO NEAREST.- SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _LL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " ❑ Industrial ❑ Open Bottom ❑Manteca E: Dia-`of Well Excavation Dia. of Well Casing ❑ Domestic/.Private D Gravel-Pack d Tracy Type of Casing Specifications. L'l Public pti - -f_1 Otherx F1 DeltaDepth of Grout Seal, Type of Grout r - I I Irrigation AApprox. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump ` Ii.P. State Work Done t Well Destruction ❑ Well Diameter ,-'Sealing Material'(top 501�f f Depth Filler Material (Below 50`1 y TYPE OF SEPTIC WORK: NEW INSTALLATIONAIREPAIR/ADDITION I I. DESTRUCTION I } INo septic system permitted if public sewer is 11 ' #"' available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units'� 4[ !Number'�of�bedrooms Character of soil to a depth of 3 feet: Z r Water table depth SEPTIC TANK Liy.-TLypOMfg. Capacity- partments No. Com PKG. TREATMENT PLT. ❑ r "~-�- � � �� Method of Disposal Distance to nearest: Well Foundation -...- Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED Cl Distance to nearest: � Well Foundation, •Property Line- SEEPAGE PITS i I Depth Size_- Number t SUMPS C1 Distance to nearest: Well ~ Foundatio r Property Line r DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accoedance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Districts Hama owner or licensed agent's signature certifies the following: "I certify that in the performance-of-the-work fol-whidi 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." II` t• - - -- T+^ --�� r_ The applicant must call for all r quired • spections Complete drawing on reverse side. Signed XC/ �. �4 Tit le: Date: .f IC � , DEPARTMENT USE ONLY t j Application Accepted by 71�_ Date. ..-�" Pit or Grout Inspection by Date Final Inspection by Date ` '�• i ! . Additional Comments: ❑ Stk 466-6781 ❑ Lodi' 369-3621 El Manteca 823-7104 ❑ Tracy 1335-6385 Applicant- Return all copies to! Environmental Health Permit/Services 1601 E. Hazelton Ave,,!P.O. Box 2009, Stk., CA 95201 - _� ._� T FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY PATE PER-.IT:--.- INFO . .. r INFO CASH--. u Je�1' E ♦ EH 14-24 1REV.a/H 51 �J t30' Ct k EH 14-29 i l II