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APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 JoaquinLocalHealth District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin CountyOrdinance No.549 for.sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,., .,.1 ,, .. y _ 1 Job Address " �(/�G J -City � . of Size � PM . - Owner's Name �% Address r� �'?r Phone f% Contract z Address. 4 :.. S� License No. "52 121� Phone TYPE OF WELL/PUMFA NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' 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 LJ Domestic/Private ❑ Gravel Pack' ❑ Tracy Type of Casing A Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ,k. El Irrigation �4pprox. Depth ❑ Eastern Surface Sea1l Installed by Repair Work Done ❑ Type.of Pump —H.P.-,- -' � ` ' �-m � � —State-Work Done Well Destruction ❑ Well biameter _Sealing-Material;(top 50') Depth "" Filler Material (Selo-W50')' t TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION.71 (No septic system permitted if public sewer is t-'% available within 200 feet.) -A Installation will serve: Residence`-- 'Commercial_ Other Number of living units: —L Number of bedrooms- Character edrooms Character of soil to a dept of 3 feet: "' .r< ` Watet'table depth i SEPTIC TANK Type/Mfg L°C� _ Capacity*. _do No. Compartments 7 I PKG. TREATMENT PLT. ❑ i'7- Method of Disposal Distance to nearest: Well ~"Q Foundation'-- I b Property Line h LEACHING LINE lil No. &Length f lines _2, - $.r3 .t Total length/size 2 C� FILTER BED - ❑ Distance to nearest: Well Foundation Property Line to LZIt ,c SEEPAGE PITS ❑ Depth , Size Number SUMPS ❑ 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, 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 sha employ any person in such manner as to become subject to workman s oompensa1ron laws oT-Caiifo�ma:' ntract-oTF jfing---oi sub contractinj]-signato 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 ust tail fo II r uired inspections. Complete drawing on revers ide. Signed ' Title: V 'Date: FOR DEPARTMENT USE ONLY �* E Application Accepted by _ Dat Area Pit or Grout Inspection by Date Final inspection by — Gz-c'�f Date l/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621: ❑ Manteca 823-7104 ❑ Tracy 835546385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ` DATE PERMIT-NO. i 1 O aEH 1 -241REV.7/851 ! �3 EH 144-26