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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 t (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 / C Z C r, e - l City Lot Size PM Owner's Name Sc o ! - t� y A// Address y - a r Ir Phone Contractor �' �Th�.v .561 Address w x-�-•-W . License No. `Phone TYPE OF WELL/PUMP:_ NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ." " ' .° fOUNDAT10N - AGRICULTURE WELL OTHER WELL_ PITS/SUMPS Dia. of Well Casing Specifications Type of Grout —7-1— I , ._ , I — I rTYPE OF SEPTIC WORK: NEW INSTALLATION '-REPAIR/ADDITION�I 1 DESTRUCTION I I (No septic system permitted if public sewer is ";W 1 -available within 200 feet.) Installation will serve: ' Residence _ Commercial— Other INTENDED USE. TYPE OF WELL PRpBLEM AREA `CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑.Oper Bottom EJ Manteca 1Dia. of Well Excavation IJ Domestic/ Private - - [J Gravel Pack ❑ Tracy rType of Casing R Public 171 Other - F1 Delta '•Depth of Grout Seal I Irrigation w --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of. Pump H. P. State Work Done Weil Destruction L I Well Diameter Sealing Material (top 501 ' T Depth Filler Material-Melow 501 Dia. of Well Casing Specifications Type of Grout —7-1— I , ._ , I — I rTYPE OF SEPTIC WORK: NEW INSTALLATION '-REPAIR/ADDITION�I 1 DESTRUCTION I I (No septic system permitted if public sewer is ";W 1 -available within 200 feet.) Installation will serve: ' Residence _ Commercial— Other 4 ; Number of living units: 'Number of bedrooms PERMIVNO. ...,C_� Character of soil to a depth of 3jfeet: Water table depth_ SEPTIC TANK f -Type/Mfg y Capacity l.9OG' No. Compartments _ PKG. TREATMENT PLT- ❑—� Method of Disposal Distance to nearest: Well Foundation 10 Property Line dos �'"_ LEACHING LINE LI No. & Length of lines �G Total length/size 't FILTER BED LI Distance to nearest: Well Foundation ;Z � Property Line SEEPAGE PITS i I SUMPS L nigpnSAI PONDS" FI DepthSize Distance to nearest: Well Foundation Number Property Line 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 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 of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must c I for all required inspections. Complete drawing on reverse side. ' Signed X c Title: Date: F R DEPARTMENT USE ONLY 1-36—yep Area Application Accepted by n Date Pit or Grout Inspection by date Final Inspection by _ n Date Additional Comments: _ --rAA_X,'-,r `" O -T ❑ Stk 466-6781 ❑ 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 ♦ EH 13-24 (REV. 1/H5 EH 14-2a FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIVNO. ...,C_� 7