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i I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. Job Address i--IT Ccity Lot Sizer` I�—A PM i I Owners Name '.�` i ? •il11@r�. Address. .. .' (J;J r.' ,,, r'�. Phone r/ r r• Contractor t Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION ❑ -PUMP INSTALLATION_❑ _ _ SY.STEM,REPAIR CJ 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications v fl Public tl Other ❑ Delta Depth of Grout Seal 'Type of"Grout I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done= Well Destruction ❑ Well Diameter Sealing Material (top 50') t Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONVIf REPAIR/ADDITION I 1 DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence Commercial Other C}'I Number of living units: �_ Number of bedrooms I Character of soil to a depth of 3 feet: C �, -------- .17,4-0 r �.Water table depth f SEPTIC TANK UEr Type/Mfgi' ' C 0 6 Ce 67 4L Capacity 2—�f�> No. Compartments : PKG. TREATMENT PLT. ❑ Method of bis osal '=+ Distance to nearest: £ Well Foundation Property Line_ LEACHING LINE LK No. A Length of lines!- 1AJ Total length/size`' '1 ' f' . FILTER BED ❑ Distance to nearest: W4I�_ Foundation Property Line �$ SEEPAGE PITS i I Depth Size ` Number - SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ � 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. i 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-contracting signature certifies the following: "I certify that in the performance offthe work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif gr 'a." The applican ust Xall for qif required Complete drawing on reverse side. SignedX Title: yH :� � .: Date FOR DEPARTMENT USE ONLY Application Accepted by v A Mk • rs1c.: Date ay Area Pit or Grout Inspection by Date Final Inspection byrD � Date�3 Additional Comments: Y ❑ Stk 466-6781 0 Lodi 369-3621 ❑ 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 t r _ FEELe MOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERINIT'NO. INFO SH +.EH 13-24iREV.Iia 5) ' Gi t EH 14.29 Dal, , t7 � ��