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APPLICATION FOR PERMIT 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 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 7, QC� - /� 9/ h City L0� Lot Size �f� PM el -7 Owner's Name ,L / �'/�? Address m � � Phone Contractor Address �� +Y License No. Phone - �� _ ;TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LlDESTRUCTION LJ r 'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 industrial ❑ Open Bottom ❑ Manteca . Dia. of Well Excavation Dia. of Well Casing 0 Domestic I Private ❑ Gravel Pack ❑.Tracy Type of Casing Specifications f 1 Public P Other Cl Delta Depth of Grout Seal Type of Grout —i I I Irrigation -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 50'1 Ni Depth Filler Material (Below i ` TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION l I (No septic system permitted if public sewer is _ . t �available within 200 feet.) Installation will serve: Residence Commercial— Other � EI Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth 6 SEPTIC TANKType/Mfg f'.Y Capacity • G�TJ No. Compartments PKG. TREATMENT PLT. ❑ l ) Method of Disposal 8 Distance to.nearest:'' Well � � Foundation _L -.- Property Line �� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well d ' `Fdu dation .ice/ Property Lined ;A '? t f Number _ ct cLa-t. ') SEEPAGE PITS: I�Depth Size / `, v r.. 3o t2.J� o�S SUMPS Ll Distance to nearest: ; {Nell .��_, FRs�ridation �Propery.'Lirle DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work will bone in accordance with San Joaquin co fit�r 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 thkin-the performancq of the work for which this permit is issued; I shalt not employ any person in such manner as to become subject to worllman's compensation_ laws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, k shall employ persons subject to workman's compensa- tion,laws of California." i ` �The�applicant must*call or p1l required inspections. Complete drawing on reverse side. ; ' !Title:' Date: �� III _ -. SiA0 gned X � - I a 1 FOR DEPARTMENT USE ONLY Date Area Z li i Application Accepted by On Pit r Grout inspection by Date �� Final Inspection Oby Date ` I I 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 95241 } l„ FEE_-'' E -_' _AFAOUNTREMITT _ ----..-_- i AMOUNT DV ED -CK - �WRECQVED BY DATE PERMIT'NO. f — INPO GASH ' y rEH13-2aiREV.riK51 lr� T EH 14-29 r. Lf