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i 1 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 �- ;3�` ";,,.• ; ,. .(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 ,■ _ City r�n't of Size .r wPM . - .N C1 Owner's•Name A dress _ Ary .Phone �� D ,i Contractor dress r e No. TYPE OF WELL/PUNA P: ANEW WELL ❑ ELL REPLACEM NT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER (❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD.- PROPLINE ;; i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA` CONSTRUCTION SPECIFICATIONS t i' ❑ Iridustriai ❑ Open Bottom - --'L] Manteca - ,Dia. of'Well Excavation' Dia. of Well Casing_ f 0 Ddmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specificationsf y ' ❑ Public , : ❑ Other * ❑ Delta Depth of Grout Seal Type of Gout L' E] Irrigation ,Apoox. Depth, ❑ Eastern Surface Seal Installed by 4 � } Repair Wor�Done ❑ Type of-Pump H.P. State Work Done r Well Destruction ❑ WeII�Diameter' "_ Sealing Material-(top 5001 r t Depth Filler Material f Belo '1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONW DESTRUCTION ❑ INo septic system permitted if public sewer is z j available within 200 feet.] Installation will serve: Residence commercial— Other I ` Number of living units: -/-- Number of b{drooms 8 r Character of soil to a depth of 3 feet: . Water table depth j SEPTIC TANK ❑ T e/Mf '- Type/Mfg 9 _Capacity ."•„ryNo^ Compartments PKG, TREATMENT PLT. ❑ _Method of Disposal . •' -44 �� ' Distance to nearest: Well Foundation Property.Line :3 __ ,_,._ LEACHING LINE ❑` No.'& Length of lines s Total length/size FILTER BED ❑ Distance to nearest: Well Foun ation .'Property Line SEEPAGE PITS ❑ Depth a 17Number r' I UMP ❑ Distance to nearest: Well `. Foundation - Property Line OTSPOSAL`PONDS ❑ 1M -' 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�`r rules and regulations of the San Joaquin Local Health District. t--'' ` - 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 6ecome 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 st cal for all require ftins ;ctions. Comple d ing on r6ree. Signed,' Title:. Date: a F R DEPARTMENT USE ONLY Application Accepted by 6/ Date / d Area L - ; Pit or Grout Inspection by Date Final Inspection by Date > Additional Comments: 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 FEEINFO AMOUNT DUE' AMOUNT REMITTED CASH RECEIVED 9Y f DATE' PERMIT-NO. t r + EHis�caev.r Hsi 70 • o f �10( �lo b-33,,