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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 'Copy 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 anti/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 Sam Joaquin Local Health District. ` L ` C Job Address T�l•5 "l h ��_� l�_ _ _ ____ ___ City Lot Si o J PM f� ` - �, r,? . Z" 9 S� Owner's Nam Q Address "3�S lJ �• Phone `�1 !`rte Contractot!��u x�42L alj Address !e�? � License No.r XKlihone- -L D(), l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NE�SEPTICNK" SEWERLINES DISPOSAL FLD. PROP. LINE ON AGRICULTURE WELL OTHER WELL PITS/SUMPS { INTENDED USE TYPE OF WELL AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca H Excavation Dia. of Well Casing ❑ Domestic/Private LJ Gravel Pack ❑ Tracy type of Casing Specifications ❑ Public ❑ Other [_-Delta Depth of Glput Seal e of Grout .� ❑ Irrigation _._.,_Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P, State Work Done 3 i Well Destruction 10 Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF.SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: ResidenceCommercial_ Other' \ Number of living-units: 1* Number of bedrooms Character of soil to a depth of 3 feet Water table depth fi SEPTIC TANK L+Y Type/Mfg r Capacity I6106 No. Compartments j PKG. TREATMENT PLT. ❑ / i Method of Diwosal Distance to nearest: Well f Foundation Property Line LEACHING LINE 2---No. & Length of lines U� �� "56 Total length/size os Y a FILTER BED ❑ Distance to nearest: Well U ' Foundation /O Property Line'TS�T SEEPAGE PITS Cl Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ a 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." r The applicant st call for II re fired inspections. Complete drawing on reverses e. Signed X Title: - r Date:C 'J d FOR DEPARTMENT USE ONLY Applition Accepted by Date Area 99 I Pit o`r Grout Inspection by Data Final Inspection b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy $355-6385 Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AM///O---��UNT DUE AMOUNT REMITTED CASH RECEIVED BY DATErrr�� PERMIT'NO. + EH 13-24IREV.tiKsl �` +.E EH 14.29 / } EI y - y