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APPLICATION FOR PERMIT SAN JOAOUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA j 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address — V 116(7 h loll-.)' City 1�4fffe4 Lot Size PM _Owner's Name- n ee Address ✓ ) 4p, Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Q , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �} DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES T ..r DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL; OTHER WELL PITS/SUMPS INTENDED USE TYPE OFWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS o ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of.Well Casing ❑ Domestic/Private ❑ Gravel Pad ❑ Tracy Type of Casing' """"-"" Specifications ❑ Public ❑ Other I ❑ Delta _Depth of Grout_Seal_ '" ,-,'Typesof Grout � ❑ Irrigation ---Approx.' 'De th ❑ Eastern g App p aste n Surface Seal Installed by � Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth . Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) I Installation will serve: Residence Commerciale+Other Number of living units: __L_ Number of bedrooms...... h Character of soil to a depth of 3 feet: SancN L661^S _^ Water table depth SEPTIC TANK © Type/Mfg j , 1?. Capacity No. Compartments �^- PKG. TREATMENT PLT. ❑ # r -Method-.of Disposal Distance to nearest: Well Foundation Property Line ,1 LEACHING LINE No. & Len dth of lines g __ —t�,r '� Total length/size. FILTER SED ❑ Distance to1nearest: Well Foundation 2-CLL Property line Y SEEPAGE PITS ❑ Depth Size Number 3 SUMPS ❑ Distance to`nearest: Well Foundation Property Line - DISPOSAL PONDS ❑ 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. 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 compensatibn laws of California." Contractor's hiring or sub-contracting signature cartifies 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 require inspection Complete drawing on reverse side. Signed X�, Title: L A�pgj, Data: FOR DEPARTMENT USE ONLY Application Accepted by —Date—�2 �U—�"�f Area Pit or Grout Inspection by Date Final Inspection b D$te ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 873-7104 ❑ Tracy 835-6385 ..— Applicant- Return-all copies to: Environmental Health-Permit/Services 1601 E. Hazelton Ave., P.-O. Box 2009; Stk.; CA 95201• FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. + EH 13.24 MEV.101M) EH 1426