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R APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . y 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 i"', 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. y .. r I City �rJfl Lot Size 'A�5 PM Job Address,�� r� �t Owner's 1Vame,� � Address Phone Contractor Address Sam 6 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ to WELL REPLACEMENT ❑ DESTRUCTION ❑ ,r• , :,.,..PUMP-INSTALLATION-❑ � ^ - ;w SYSTEM REPAIR ❑' � " " '� OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE (FOUNDATION s AGRICULTURE WELL OTHER WELL PITS/SUMPS '{ i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I �a Ll Industrial �❑ Open Bottom ❑ Mahteca Dia. of Well Excavation Dia. of Well Casing s ❑ Domestic/Private'" �❑ Gravel Pack ❑tTraSpecifications � Type of p ❑ Public O Other= ❑ Delta Depth of Grout Seal Type of Grout .: trri ation'�� —Approx. Depth ,❑'Eastern Surface Seal Installed by w Repair Work Done LlType oa Pump —` H.P. State Work Done Weil Destruction ❑ We1I Diameter € Sealing Material {top 50'1 tT Depth " - Filler Material (Below 50'i L' --TYPE OF SEPTIC WORK: .NEW INSTALLATION: REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is . available within 200 feet.) y J.4 Installation will serve: .,ResidenceAl,Cominercial'; Otherst•.- y r• _ ,_ _ ®-- F °7 Number of living units: ,Number f bedroo s yam- ;;y`.� .� r Character of soil to a depth of 3 feet: . ' � Water table depth r �!� �,�d I No. Compartments y j -.-•-` SEPTIC TANK [ Type/Mfg Capacitvrt ! .� Method of Disposal PKG.TREATMENT PLT Fr— ---�- ` l T, ! Distance to nearest: Well 00* Foundation Property Line r.`. Total length/size LEACHING LINE No. & Length of lines o v FILTER .BED ❑ Distance to nearest: Well Foundation r Property Line — SEEPAGE PITS ❑ Depth i Size Number I Foundation- Property Line' ❑ Distance;to nearest: Well Foundation- _ DISPOSAL PONDS ❑ =' ` '-. I hereby certify that t 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. ,. n +- Home owner or licensed agent's signature certifies the fallowing: "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." Contractor's hiring'or sub-contracting signature certifies the following: "I certify that in the performance of the wor.k.for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." ='f t , The appl' n ust ca f II ired inspections. Complete drawing o r erse side. { 'r 6 n Signed Title: Date:FOR DEPARTMENT USE ONLY ' I F. ��C) Area `S Application Accepted by • ` Date - _ - : rte/�— i (late Final Inspection by ate) Pit or Grout Inspection by- ' � � L ` l I Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3821 KManteca 823-7104 ❑ Tracy 835-6385 G Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE 7 AMOUNT DUES AMOUNT REMITTED CK H RECEIVED BY. DATE PERMI7'NO. INFO //�� + EH 13-24 IpEV.5 i n 5) �3r ..� 0 0 K✓ } 1�-�' �S r EH 14-25 ,�,