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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 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. c n Job Address /60S-6 O�I�� r` City f1r)-t�' "N Lot Size —7 ACaes P11+! Owner's Name `�'}^�Le'LAddress r �D Phone >i Contract or f + M (?ARGI(� Address lu�6 I License No.2(/-2>7A 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 I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Dorri stir/Private D Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout --- I I Irri0lion _..Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done—-- Well Destruction ' ❑ Well Diameter Sealing Material Itop 501 i Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION Ile DESTRUCTION I I (No septic system permitted if public sewer is ° / available within 200 feet.I Installation will serve: Residence 1% Commercial 2 other h) Number of living units:.__J__ Number of b rr000ms ,r Character of soil to a depth of 3 feet. —�"ti R _ Water table depth r c 'SEPTIC''TANK' ElType/Mfg Capacity 0�3' No. Compartments /PKG. TREATMENT PLT. ❑ Method of Disposal "i Distance to nearest: Well Foundation Property Line �.. - / '..LEACHING LINE LSI' No. & Length of lines 1 7 Total length/size -70 FILTER113ED ❑ Distance to_nearest: Well Foundation Property Line' SEEPAGE PITS I I Depth T"""'Siie � Number' � SUMPS L7 Distance to nearest: Well -.. m - Foundation Property Line, DISPOSAL PONDS D I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale 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 compensation laws of California."Contractor's hiring or sub-,contacting signature certifies the following: "I certify that in the pert rmance of the work for which this permit is issued, I shall employ persons subject to wofkman's compensa- tion laws of California." The applicant must call for all required ins tions. Complete drawing on reverse side. f Signed�XTitle: f �f~ Date: USE ONLY *;= - ga&Z- j Application Accepted by Date Alp Area d Pit or Grout Inspection by Date Final Inspection by DateO-�� Additional Comments: ❑ Stk 1466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - q turnall„coples to;-Environmental_Health.-Permit/Services.1601-E.,.Hazelton.Ave,,..P.O=..Box-2009,Stk-,CA-95201 «- FEE AMOUNY-61 E— AMOUNT REMITTEI] I p(CEIVED BY DATE PERMIT NO. INFO y�fj y3l'CASH , �[l rx�� `fin I + EH 13-241REV.rinsY `' T,Z) �I'�l� ou (J b Jr'�S i EH 14-26 111 z. .