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t,"- . . IV \. APPLICATION FOR PERMIT —off •15, -\k �� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELFON AVE., STOCKTON, CA' L � ,� Telephone 1209) 466-6781 ( ya}�1a 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 o. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address - '- L-• //1 .i %, ' 4 city C-0 J- /Lot/Syize�c n_-_'L"- PM Owner's Name�t e�'t��.-��-u--�^�+-% ,,AJ)ddressss ��E�' F . T•�-lit LCL- le7'• l"LL'"rPhone — Contract ."r /' Address License No 51 .1-2(� Phone «• ICJ TYPE OF WELL/PUMP: NEW WELL ❑ z WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ — 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 �. c ❑ Industrial El Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout El Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') \- Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 10'' REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units:_�_ Number of edrooms _ Character of soil to a depth of 3 feWater table depth C,` SEPTIC TANK Q"' Type/Mfg 61,:"c �y�>_rt.t-*:=z Capacity_L2C G No. Compartments PKG. TREATMENT PLT. ❑ f 1 Method of Disposal Distance to nearest: Well + Foundation I U' Property Line S t LEACHING LINE No. & Length of lines C, Total length/size x FILTER BED ❑ Distance to nearest: Well /00r Foundation /0 Property Line S �� SEEPAGE PITS Ll Depth 9 Y Size 77 Number r SUMPS ❑ Distance to nearest: Well 410', Foundation/() Property Line 'r —' 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 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 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." The applicant st call for elkrequired inspections. Complete drawing on reverse side. _ tt i Signed X `C � `� � TRIe: \,). f Date: - i FOR DEPARTMENT USE ONLY Application Accepted by Data y Pit or Grout Inspection by Data Final Inspection by � Date` � r Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. HazeRon Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. IN CASH t EH 13-]4(REV.1/esl EH to 26 , c'DO L "'1