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Q-3' A 1� x APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466_6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t 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 � �� / City Lot Size L ete-1-1— Ph Owner's Name Q. Addrephone Contra ctor's`Name (cense No. Phone e% 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 ❑1 d t'I n us ria ❑ Domestic/ Private ❑ Public ❑ Irrigation Repair Work Done ❑ Well Destruction ❑ ) ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Gravel Pack ❑ Tracy Type of Casing ❑ Other ❑ _Delta Depth of Grout Seal --Approx. Depth _0.. Easterri Surface Seal Installed by Type of Pump , � %i H.P. State Work Done _ Well Diameter Zf.J :': Sealing Material (top 501) Depth `-;,� F Y Filler Materia! (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION X DESTRUCTION ❑ fNo septic system permitted if public sewer is 1 r f available within 200 feet.) Installation will serve: Residenc 1 e Commercial Other 4:• .1 , ti J Number of living units: - Number of bedrooms Character of soil to a depth'of 3 feet: L_.(�iW Water table depth _ SEP4TIC TANK ID Type/Mfg U Capacity No. Compartments PKG. TREATMENT PLT`❑ Method of Disposal I Distance to nearest: Well Foundation Property Line Dia. of Well Casing _ Specifications Type of Grout LEACHING LINE No. & Length of lines 1 Total-length/size FILTER BED 10 Distance to nearest: Weil �� Foundation ` � �, y 1 Property Eine - 13 SEEPAGE PITS ❑ Depth ----size � `�` p - I Number SUMPS# 4 1E] Distance to nearest: Well I Foundation Pro "e p} rty Line DISPOSA(PONDS I herebycg`rtify that I havi`prepared this application and that the work will be done in accordance with San Joaquin(county ordinances, state l rules and,�egul'ations of the�San Joaquin Local Health District. i laws, and R Home owner or licensed agent's signature certifies the foil owing: "I certify that in the ' employ performance•of the work -for which this permit is issued, I shall not p y an y person i such m6nher as to become,subiedt to workman's compensation laws of California." Contractor's hiring or sub -contracting signature certifies the following: "I certify_ that in the perfo►mance`df the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California.': 1 ,f 1 The applicant must call for II re ins c ' ns. Complete dra v ing on rev rse side. C` /j rt+fif; ii � Signed /CSG/ _ � � ,Title: ��/ i Date: e t + FOR DEPARTMENT USE ONLY / # Application- Accepted by 4 rnJ I Date �r r� Area �y Pit or Grout Inspection by Date Final inspection by ;. 1. s " Date Additional Comments: r-- - ❑ Stk 466-6781 ❑ Lodi 369-3621 . ❑ Manteca 823-7104 ❑ Tracy. 835-6385 Applicant - Return all copies to: Environmental Health Permit/Service's 1601 E., Hazelton Ave., iP.O. Box 2009, Stk., CA 95201 + EH 1324 (REV, EH 14-26