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APPLICATION FOR PERMIT .h4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 wall/pump and the Rules and Regulations of the an Joaquin Local Health District. 7. vs Job Address �r City L "Jef- Lot Size PSN Owner's Name f--Obe, � Address 19077 �' V+r t�-4e^- Phone -Flf Contractor Address License No. Phone TYRE OF WELL/PUMP: NEW WELL REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATION V SY5 • EPAIR ❑ OTHER ❑ ,,DISTANCE TO NEARE TIC TANK •3 s SEWER LINES -.._---__�; ISPOSAL FLD. PROP. LINE FOUND AGRICULTURE WEL OTH LL PITS/SUMPS INTENDED USE TYPE OF WELL :10 AREA CONSTRUCTION SPECIFICATIONS Lt IndJtrial Ope om Manteca �iia. Well Excavation Dia. ell Casingnvvate ❑ Gravel Pack Tracy Specifications ❑ Public ❑ Other Delta Depth of Grout Sea ! Type of Grout ❑ Irrigation Depth ❑ Eastern Seal Installed by Repair Work Dane © Type of Pump �� .PSA�Lx H.P. State Work Done Well Destruction ❑ Well Diameter ling. Material (top 60') Depth Filler Mate elow 501 TYPE! OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DPST4UJZTION ❑ (No septic system permitted if public sewer is 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: Water table depth .0 d SEPTIC TANK ❑ Type/Mfg G Capacity /(. 190 No. Compartments ' PKG. TREATMENT PLT. ❑ t I Method of Disposal Q Distance to nearest: Wellp � Foundation Property Line __.._ LEACHING LINE ❑ No. & Length of lines 2" Total length/size 200, FILTER BED ❑ Distance to nearest: Well Foundation Property Line I�I SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well ��O Foundation /24" Property Line 5?�� DISPOSAL PONDS ❑ 1 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. 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."Contractors 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 required inspecti n omplete drawing on reverse side. Signed X Title: Date: 2/1? /FOR DJOARTIVIENT USE ONLY r7 Application Accepted by Date �� Area Pit or Grout Inspection b Inspection y Oat inal spection by � Date Additional Comments: ,/ /L wo ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUN�T/DyUE AMOUNT REMITTED CA RECEIVED 8Y DATE PERMIT'NO. + EH 13-24IPIEV.1/86) -76) EH 1426 /