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1 J +.. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA M Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heEeby 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City h<-:257— Lot Size PM Owner's Name Address Phone Contractor /edp°� r Address+>'O� License No. as3f Phone TYPE OF„WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑' - DESTRUCTION-❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER-0 r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE Q FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 1-1 Public D-Other. „,.;,0-Delta Depth of Grout Seal Type of Grbut _ :x a: I I Irrigation %-�v�„3^_',.Approx. Depth l I Eastern Surface Seal Installed by ' Repair Work Done s❑ Type of Pump H.P. '" State Work Dorie -. _.. Well Destruction i© Well Diameter Sealing-Material Itop 501 Depth Filler Material {Below 50') TYPE OF-SEPTIC,WORK.,,-NEWIINSTALLA.T.ION1REP_AYR7A-DDTTION_t.l-,f]ES7TPdJCTJ.OhllV_L-I--MosaWic.system-permitted if public,sewevis,— available within 200 feet) Installation will serve: Resi ence '< Commercial�JOther- I Number of living units: Number of bed7y, o ms- F Character of soil to a depth of 3 feet: C y F.. Water table depth SEPTIC TANK T Type/Mfg 4� C T 07 CO'l/l E'R Capacity!t�Z-4�T-------NiE Compartments PKG. TREATMENT PLT, ❑ 1 I ' \ _ Method of Disposal Distance to nearest: Well' Foundation Property Line LEACHING LINE No. & Length o� f lines 3 �� F� Total length/size 7-70 /�'T FILTER BED ❑ Distance to nearest: Well�.. Foundation `� Property Line SEEPAGE PITS i'I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation 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,`"end rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 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: "I0', ce iIf 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 r all equir ns s. Complete drawing on reverse side. I Signed X Title: � ��L Date: a� 7 FOR DEPARTMENT USE ONLY _ Application Accepted by bate ff/�� 'Area 1 t _ t Pit or Grout Inspection by " Date Final Inspection by Date Additional Comments:,n �f ❑ Stk 466-6781 fl 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 FEE r INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE /P7ERRMIT'N0. + EH 13.24(REV.liK5) / v t^i -0 j��/ J/ EH 14-26.. Lft— 4 G7