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x : APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT I 4 1601 E. HAZEL T ON AVE, STOCKTON, CA Telephone (209) 466-6781 ' r 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. ,-- Job Address - r ` City Lot Size r+3 oqa, pM ' Owner's Name ! Address Phone Contractor „ 6�� ! Address License No.C.?MS-2-2/ Phone 36 j 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 g V. FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS/SUMPS ,� y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial s ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f Dia. of Well Casing ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications 1`7 Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx.-Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump . H,P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 501 j t� Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION i I (No septic system permitted if public sewer is ; II available within 200 feed Installation will serve: 1 Residence ✓Commercial_ Other \v� Number of living units: Numberlof b drooms 3 Character of soil to a depth of 3 feet: � � � 01 „,� Water table depth SEPTIC TANK PRS Type/Mfg ._!_l - 1t�(0_ Capacity No. Compartments PKG. TREATMENT PLT. ❑ - Method of Disposal I 1 � Distance to nearest: Well 7d i Foundation e-2_0 r Property Line r L - LEACHING LINE 'L� No. & Leng l kof lines 7 V6 Total length/size FILTER BED ❑ Distance to'nearest: A'Well 70 ' Foundation” �"("+ Property Line 36 + � � f SEEPAGE.PITS Il� ep Dth S `-Size � 6 � be I ` ' Numi SUMPS j.,t. L1 Distance to nearest: Well 1 I r' i 'n - 3d ! t _f_cr� Foundation Property Line N , DISPOSAL PONDS 1❑ 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, ar.6 \ r rules and regulations of the San Joaquin Local Health District. f -.f Home owner or licensed-agent's signature'•certifies-the-following: j;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 workfian'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',1 shall employ persons subject to workman's compensa- j tion laws of California." � The appficamLmust call for all regoiredjrnspections. Complete drawing on reverse side. f 9 Signed � - Title: Data: FOR DEPARTMENT USE ONLY ppii tion Accepted b DateArea a- / Pit Grout Inspection b pate Final Inspection Date dditional,Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 rq ❑ Manteca 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 4 � f FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +-EH 3-24(REEV. .EH 1 4-2Z,fS 7/ (�