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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 Local Health District. S" �ICity L0 t9 Lot Size � � PM Job Address 33 Owner's Name �¢�{ 411-1d Address Phone' Contractor d Address /2- PY-, �_t§c'/A?" �C/ License No_ 31(9- 'Z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE:TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L] Industrial - ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing 9 Specifications E] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ( ,---Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. State Work Done f Well Destruction ❑ Well Diameter Sealing Material {top 50') x+ F Depth Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION El DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) " Installation will serve: Residence ✓ Commercial, .Other Number of living units:I Number of bedrooms Q ! Water table depth Character of soil to a depth of 3 feet: I SEPTIC TANK LlType/Mfg AJ IS C Capacity 00 No. Compartments PKG. TREATMENT PLT. ILMethod of Disposal 110-1' % -, f I 1 Property Line Distance to nearest: Well_r S a _ Foundation I J Total length/size LEACHING LINE LYNo. & Length of lines 3 C1� FILTER BED [__1Distance to nearest: well 10 Foundation 3 A r Property Line SEEPAGE PITS ❑ Depth aZ� Size 30 Number 3 ! + SUMPS El ' Distance to nearest: Well / 5LI rr ;Foundation �5 I Property Line EG - k DISPOSAL PONDS ❑ I i I hereby certify that 1 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 wo'rkman's compensation laws of California." Contractor's hiring or sub-contracting signature certifieli-lKe 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 call fo all re fired inspections. Complete drawing an reverse side. �, 1. Signed Title: W d( Date: ' FOR DEPARTMENT USE ONLY M h Date —` Area Application Accepted by p5 pate 7Final Inspection by��C-zr' Date !_ Pit Y Grout Inspection by R _ _ I ..•- -* Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M 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 C RECEIVED BY DATE PERMIT N0. INFOCo.- �c + EH 13-24{REVS/85) �� Xi--1 V�� EH 14-26