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r i' 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. J� Job Address r - � f '[I®U It�iJ City ,p0 Lot Size PM Owner's Name d1nU Address 6Gya-e_ Phone Contractor >',4 (C-(_ Address a License No. ) ZS_T a Phone ~ TYPE-OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION E PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK —,SEWER LINES DISPOSAL FLO. _ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private I ❑ Gravel Pack Q Tracy Type of Casing Specifications — M Public n Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx: Depth- 1 1 Eastern— =-.r-M-w Surface Seal Installed by ,— •�« Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seajing Material itop 50'I Depth Filler Material !Belo i I TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRIADDITION DESTRUCTION I 1 (No septic system permitted if public sewer is -� available within 200 feet.! Installation will serve:. Residence— Commercial— Other Number of living units: Number of bedrooms 1 t it Character of soil.lo a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation . """Properfiline 4\ N, O�rNrr LEACHING LINE No. &Length of-,lines Total tal length/size 1 FILTER BED ' ❑ Distance to nearest:.. Welles Foundation ., Property Line` ` P i PIT SEEPAGE S l I Depth Size Number' SUMPS Y ❑ Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ � I hereby certify that I have prepared this application andthatthe`work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of.the San Joaquin'Local Health Di§trict. : "I certify that in the performance of the work far which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following 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 ai required.inspections. Complete drawing on reverse side. Signed X Title: > Date: 1 � ! f f R DE RTMENT USE ONLY Application Accepted by Date O 49 Area Pit or Grout Inspection by Date Final Inspection by Date` ?) Additional Comments: Comments: D Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E:414azelton Ave.;P.O. Box 2009, Stk.,CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24(REV,1 i H 5) EH 14-26