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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT P r 1601 E. HAZELlON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) Application is heieby 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 AddressCU-+ / - r��" City Lot SizePM_ L. 110� Address= � �"�ie 7a7 'q0?Owner's Name Contract r Address _/r 'r67 License No. t" Phon -S��S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ rf r SYSTEM REPAIR ❑ OTHER ❑ ' 1 DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES DISPOSAL FLD. POOP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS it - t� INTENDED USE _ TYPE OF WELL PROBLEM-AREA CONSTRUCTION SPECIFICATIONS ` - ❑ Industrial T ❑ Open Bottom _111.Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack t ?^'C] Tracy i Type of Casing Specifications I fl Public ❑ Other Ff ❑ Delta Depth of Grout Seal Type of Grout - i 1 1 Irrigation --Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. f State Work Done Well Destruction ❑ Well Diameter -Sealing Material (top 501 c� Depth 1 - Filler Material (Below 50') "4 TYPE OF SEPTIC WORK: NEW INSTALLATION "-REPAIR/ADDITION I. I DESTRUCTION l I (No septic system permitted if public sewer is O v a available within 200 feet) I Installation will serve: Residence Commercial_J.-7 ' Number of living units: --,/— Number of ooms� Q0 Character of soil to a depth of 3 feet: Water table depth ` SEPTIC TANK Type/Mfg r Capacity No. Compartments PKG. TREATMENT PLT. El f` Methad of Disposal Distance to nearest: Well=:�) Foundation.. /O{ .�' Property Line- . - t HD'ti aC LEACHING LINE &--No. & Lerngth of lines _` Total length/size t FILTER BED ❑ Distance to nearest: Well r Foundation:=,�� Property Line �! SEEPAGE PITS iAK Depth Size' 7 Number SUMPS 0 Distancerto nearest: Well/.�� Foundation—ZIQ -- 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 persoh'in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature certifies 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 mu �11or all req d inspections. Complete drawing on reverse side. 1 Signed X Title: V• Date: / ©ct r 17 FOR DEPARTMENT USE ONLY l Application Accepted by Date Area Pit or Grout inspection.by Date ` ✓��V Final Inspection by Additional Comments: z ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to:,Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. INFO f + EH 13-24{REV.i)H 5) k7_2A