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yJ F* - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 091 466-6781 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. r' ,�4it CsE? Lot Size PM Job Address �� C .�,� City�s Owner's Name Address ._�C -1 �— Phone Contractor's Name License 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - Specifications ° ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation !�pprox. Depth'—�9 Eastern Surface Seal Installed by Repair Work Done E] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'1 C Depth Filler Material IBelow 501 �. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is � available within 200 feet.) Installation will serve: Residence_ Commercial_... Other �ZfJF \ _////� ��G Number of living units: _- Number-of bedroom_s _ -. _ - w— ^ r 'F P-- 71 '+ - Character of soil to a depth of 3 feet: Water table depth __ V SEPTIC TANK- -r 15d Type/Mfg--- - Capacli'__ ^` No. Compartments 3 PKG..T,REATMENT.PLT. ❑ -�4 Method of-Disposal----- -__. — --• _}- Distance to nearest: Well /2�4/ Foundation Property Line LEACHING LINE ❑ No. & Length of lines A67 Q Total length/size d FILTER BED Distance to nearest: Well Foundation��42�T Property Line 6— SEEPAGE PITS ❑ Depth Size Number I SUMPS ❑ Distance to nearest: Well Foundation Property line € DISPOSAL PONDS ❑ i } t 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. I 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, Lsliall 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 a squire inspections. Complete drawing on reverse side. A Signed ` r. Title: Date: �•� k ^ FOR DEPARTMENT USE s . Application Accepted by Date 1 Y Area ' Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ElManteca 823-7104 ❑ Tracy 835-6385 'Applicant_- Return all-copies to:"Environmental.Health.Permit/Services 1601.E. Hazelton Ave.,P.O. .Box 2009, Stk., CA 95201 r. - - -� • � - 1. •� f I Y - y-- - FEE-" -AMOUNT DUE AMOUNT"REMITTED' CK —RECEIVED BY T `— 'DATE- --PERMIT`NO, INFO CASH R. + EH 13-24{REV.101831 O ' FH 7L7F