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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE.T ON AVE., STOCKTON, CA r Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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 k 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 i Local Health District. k p Job Address 1' Rd City 6r* 0,A" Lot Size PM I Owner's Name 7l L DWler-$AddressAr Phone Contractor_� J'Address -0.2—I7lrV� f7n ✓ License Nn. 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 ElOpen Bottom ❑ Manteca .� Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ""type of Casing Specifications I F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation __.Approx. Depth l I Eastern 2 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 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/AODiTION I't` DESTRUCTION i I (No septic system permitted if public sewer is _ available within 200 feet-) f Installation will serve: Residence— Commercial,/— Other Number of living units: Number of bedrooms l� °�1eo_'p Character of soil to a depth of 3 feet: 5;4Z;K �mw Water table depth SEPTIC TANK ❑ (!Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑_" Method of Disposal $, .+'-Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ ;,No. & Length of lines Total length/size �S` :7 tAt7 FILTER BED Distance to nearest: Well PVV16 ie Foundation 1 _- Property Line 30 / I SEEPAGE PITS l 1 ..Depth Size Number 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 mariner as to became subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature certifies the following: "t 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. a The applicant mu call for all required inspections. Complete drawing on reverse side. J Signed X Title: Date: �y r FOR DEPARTMENT USE ONLY I Application Accepted by 7ZZ) Date Area Pit or Grout Inspection by Date Final Inspection bDate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return at] copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO, INFO I - 64,(� CASH /�f o1.33 �:.- EH 14-I6 tt