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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 6. Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) LApplication 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 t Local Health District. f-� p ,,,,,,,,nn__ �' �/ f !� ` Job Address � [ 7 1 1 b �-Cf City JC L Lot Size //oma PM LOwner's Name '` a t4-o-:j 7 Address Phone Contractor 4 14G Address (� �i /��O M7&,4 License N4� Phone L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION EI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ L INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications L n Public F1Other n Delta Depth of Grout Seal Type of Grout 1 I Irrigation _..Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 L Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other \\ `. Number of living units: �_ Number of bedrooms Character of soil to a depth of 3 feet: 4L'® Water table depth 1 SEPTIC TANK ❑ Type/Mfg A Capacity� No. Compartments 6 PKG. TREATMENT PLT.❑ .L '� -T Method of Disposal Distance to nearest: Well- 6—�- Foundation Property Line-.7F- (� LEACHING LINE 1� No. & Length of lines Toottallllength/size IN. FILTER BED ❑ Distance to nearest: Well Od Foundation.fPJLL- Property Line y` SEEPAGE PITS I I Depth Size Number L SUMPS Cl 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, and rules and regulations of the San Joaquin Local Health Di3trict. �. 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." r. The applicant must call for all quire Inspectio Complete drawing on reverse side. t-r Signed X �z �� Title: 6"6—0--&--, Date:IMP Fl ARTMENT USE ONLY 7 Application Accepted by � �� Date �/�� Area �J Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ 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 V INFO AMOUNT DUE AMOUNT REMITTED CCK N RECEIVED BY DAT/E� �y PERMIT'NO. SEH 1334mEV.1/x5) 6. EH 1.26