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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTR CT 1601 E. HAZE 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address /// r D To ��v Co Law City Lot Size PM ff Owner's Name h �� Address Phone Contractor kolm,*),\Pt_Address L License No. hone TYPE OF WELL/PUMP: NEW WELL O 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 ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing \ ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications FI Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout -- 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 ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION AIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence` Commercial_ Other Number of living units: J_ Number of bed r oms 726 Characterof soil to a depth of 3 feet: Water table depth' SEPTIC TANK 3--Type/Mfg ��++ ^ pe/Mfg �1.0C_r-, F=, — Capacity-J,22.01:?_ No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well �1J�L Foundation' 6 J�Property-Line 1 FX94- LEACHING LINE L9'--No. & Length of lines � Total length/size FILTER BED stance to nearest: Well A]4!5 Foundation a_ i _ Property Line I� SEEPAGE PITS t-F epth -� Size Number SUMPS Ll Distance to nearest: Well Foundation _62,4::� 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature c 'fres 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 la f Caliw ni . The applica u ca 19 II r uire i speyttoRf te drawing on reverse side. / Signe Title: ( Date: 1 -ete FOR DEPARTMENT USE ONLY Application Accepted by Date —(--L— V'"_—Area 1� i or Grout Inspection by final Inspection by l�A� Datek� / Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O 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 95201 FEE INFO AMOUNT �DUE AMOUNT REMITTED CASH RECEIVED BY DATE '400 EH PERMIT NO. EH EH 74-26(REV.f i n s) `r / / /' ,/{ �� ih-Al