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am APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in TripLcate) aw 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/purnp and the Rules and Regulations of the San Joaquin Local Health District. f .Job Address _ _ � City Lot Size � PM Owner's Name _ a ✓ ddress Phone t' an 47 Contractor _ er'�.2x ss rT ;cense No./, Phone,[, % TYPE OF WELT_/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O r. PUMP INSTALLATION O SYSTEM REPAIR L.1 OTHER O DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE _- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I-1 Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing I I Domestic/Private CI Gravel Pack O Tracy Type of Casing Specifications I I Public I l Other F1 Delta Depth of Grout Seal Type of Grout I I Irngation ___ Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done 11 Type of Pump H.P. _ State Work Done Well Destruction Fl Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION W REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) S Installation will serve: Residence I Commercial Other Number of living units: _t_ Number of bedrooms Character of soil to a depth of 3 feet- _ Water table depth SEPTIC TANK Cl Type/Mfg t Capacity– L No. Compartments .. PKG. TREATMENT PLT. F1 �+ Method of Disposal _ Distance to nearest: Well /��+��r)� Foundation/ 0 _ Property Line6__42am — LEACHING LINE F1 No. & Length of lines — , O Total length/size1 0. 19 FILTER BED O Q Distance to nearest: Well /� Foundation -_Z6 Property Line_.�a 0 SEEPAGE PITS I I Depth __� Number 3 L L I Distance to nearest: Well j_ (�_ Foundation _ Property Line DISPOSAL PONDS Il I hereby cortify 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 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 parson 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applican 1 us all f r all re r d i spections. mpl drawing on reverse side. CV� Signed X _._ Title: _ _ Oates. FOR DEPARTMENT USE ONLY pplication Accepted by L �� Date ? p�/� � Area l i or Grout Inspection by Data =1 Final Inspection by Y1 Date -�n Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 O Manteca 823-7104 O Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT N0. EH 1324 IREV.i I n 5) r EH 14 26 2C' )C o 9o --71\,