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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL H' EALTH DISTRICT + 1601 E. HAZEILTON 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. ry L } 7tS .,,�/j i •�, Job Address 7 ^(/�fK city Lot Size _ , " PM' 1: ... lr. A. `.L Owner's Name Addfess j /S-7.5 7 Phone - _ Contract f .3,&- Adidress - 7 b l Llcens No. Phone �Q TYPE OF WELL/PUMP: l NL.EW WELL 11 WELL.REPLACENIENT D" "� DESTRUCTION O PUMP�INSTALLATION ❑ l y SY�TEM Pt PXAIRfO1 L c OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES 'DISPOSAL FL-D.— PROP. LINE ti FOUNDATION ! AGRICULTURE WELL OTHEfR WEI_b PITS/SUMPS INTENDED USE TYPE OF WELL i PROBLEM AREA CONSTRUCTION SPECIFICATIONS ? '� ❑ Industrial aL Open Bottom ❑ Manteca Dia. of Wellf`Excavation Dia. of Well Casing ❑ Domestic/Private ❑ &avel Pack ❑ Tracy Type aT Gasing ' Specifications ❑ Public El Other 1•�^ ❑ Delta 1111 Depth of Grout-Sed Type of Grout �- ❑ Irrigation _Approx. Depth,`❑ Eastern ) Surface Seal Wstalled by-,-, Repair Work Done ❑ Type of Pump H.P. / }��ate Work Done Well Destruction ❑ Well Diamet it S!alirig Mater�ia�!j.50') �^ } Depth eller Materialdf3elow TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADS ION Q DESTRUCTION,[]"-(No septic system permitted if public sewer is -available within 2.00_ feet.) Installation will serve: .Residence Commercial— Other T ' Number of living units:__Z_ "Number o drooms ;a Character of soil to a depth of 3 feet: I z `i' • ,Water table depth o SEPTIC TANK tT Type/Mfg Capacity__ No. Compartments PKG: TREATMENT PLT.❑ . r Method of Disposal Distance to nearest: !Well�i _S D Foundation _ Property Line LEACHING LINE 2K-No.No. & Length of lines U Total length/size i K, i FILTER BED ❑ Distance to nearest: i WeIIT�Q Foundation__ZQ Property Line Zi k SEEPAGE PITS DepthSizes 1 3 f�lumber SUMPS ❑ Distance to nearest: i Well�� Foundation �� Property Line DISPOSAL PONDS ^© I hereby certify that 1 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, 1 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." I The applica_ ust call for req*e dinspections. Complete ora� on reverse - ` Title:,-=, Date: f r Signed k rY ! FOR DEPA TMENT USE ONLY _ ----4ipplication Accepted-by�... - -- - -- •----— .'Dater - •,•O Aiea_"`c J_ r l �J it r Grout Inspection by Date Final Inspection by ate i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-31321 ❑ Manteca 823-7104 ❑ Tracy 835-6386 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE 1 jNFO AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE PERMIT NO. I , +[111324(REV.1!65) { EH 1426