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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA �1 Telephone (209 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; 4 ,...,.- (Complete in Triplicate) Application is herebyY �3 de t 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. �j C '� �s y ;7L T�5 ('Cry i///so'g ' 5, _ _ City cJ f Lot Size PM Job Address Owner's Name i �11� S Address ©100 Fj$�751q� d- Phone916 �F`3 r9 ?�f'2- w Contractor C� � —� Address � � License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ j i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER K i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �+✓i� �+ 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 FI Public Cl Other ❑ Delta { Depth of Grout seal Type of Grout---. I 1 Irrigation --Approx. Depth I I Eastern Surface Seal Installed by §§§ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Searing Material (top 50'1 — Depth Filter MateriaF(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is ' f,I available within 200 feet.I Installation will serve: Residence_ Commercial . Other Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT, LI Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Welt Foundation Property Line i SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 + I 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. 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 of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applica st I for all required inspections. Complete drawing on reverse side. + Signed ' AS Title: O �� Date:OF �y� f �1 _ FOR DEPARTMENT USE ONLYpplication Accepted by ZJDate Area Pit or Grout Inspection by Date Final Inspection by '' Date ' Additional Comments: 2rZv�'� . ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante a 823-7104 ❑ Tracy 835-685 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 RECEIVED BY DATE PERMIT'ND. INFO �^ ..EH 13-24 IREv.F/As) EH 14-2e a`O i