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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 (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 LocalHealth District. n Job AddressCity Lot Size �/ D PM - h ' � (16 Owner's Name "- • -` _ address "/ � S,� Phone Coritractor "Address ! / 7V �'4 License No I�Y 99 Phone/ � � TYPE OF WELL/PUMP:; '-N NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ { JPUMPINSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. .PROP. LINE j OUNIJATION AGRICULTURE WELL OTHER WELL ?ITS/SUMPS INTENDED USE, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Wh 3. ❑ IndustrialElOpen Bottom ❑ Manteca Dia. of Well Excavation . Dia. of Well Casing r 1:1 Domestic/Private ❑ Gravel Pack LI Tracy Type of Casing Specifications 1 i Public in Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation Y,--Approx. Depth i I Eastern Surface Seal Installed by ` Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction i ❑ Well Diameter Sealing Material (top 501 i Depth Filler Material (Bel w 50') ¢ t TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIADDITION DESTRUCTION I I INo septic system permitted if public sewer is I ! available within 200 feet.) Ell Installation will serve: Residence Commercial_ Other Number of living units: i Number of bedrooms 1=� ^J 5, Character of soil to a depth of 3 feet: A Water table depth ' SEPTIC TANIC �;�' ,❑t. Type/Mfg Capacity No_Compartments PKG, TREATMENT PLT. ❑N ., Method,of Disposal a � Distance to nearest: ell Foundation Property Line G i LEACHING LINE w, ❑ Nq- & Length of lines t Total length/size FILTER BED ,�� zf ❑ Distance to nearest: Property Line SEEPAGE PITS f l L 3 Depth+� �y A Size ��r� Num r SUMPS i LI; Distance to nearest: Well u dation�_�Property Line DISPOSAL PONDS ❑it_ .7 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 f� rules and regulations of the San'Uo64uin,Local Health District. y Home owner or licensed agent's�igirature,certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any persori'in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: 1 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." i c The applicant st call for`;'A/V uired ins ctions. Complete drawing on reverse side. Signed X Title: _ '' Date: ' FOR DEPARTMENT USE ONLY ; (� Application Accepted by - .._[. „•�:,..,. g_ - ,:ate ° ��J Area t r, ! U t q� Pit or Grout Inspection bV r Date Fal Inspection by Date t fJ Additional Comments: Luh? Q/r Ti 'E fie[ El Stk; 466-6781 ❑ Lodi. 3 ❑ Manteca 823-7104 ❑ Tr cy 835-63854 Applicant - Return all copies to: Environmental Health Permit/services 1601 E. Hazelton Ave.~P.O. Be,2009, Stk., CA 95201 n FEE"" AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO. r` '�"] �/ + EH 53-24{REV.1/)151 � / 0`-�� F� � a EH 14-2a [