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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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. p Job Address ,05�©�• l� 1 City Lot Size �2 _ PM �t �Owner's NameO � .A " "" Address Phone _7T"1- 1 Contract r ,-Address i.©. C>f�1C �� 1 License No. �� Z�Phone��a S1 0 TYPE OF WELL/PUMP: NEW WELL FI WELL REPLACEMENT D DESTRUCTION L) PUMP INSTALLATION F1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. _ PROb. LINE FOUNDATION AGRICULTURE WELL OTHER WELL I PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing * Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('1 Public 0- F-1-Other - - - Cl Delta Depth of Grout;Seale_ Type of Grout I I Irrigation j _;Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done Well Destruction ❑ Well'Diameter `' Sealing Material (t6p 501 Depth -?�� Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION.I'I' `DESTRUCTION I I (No septic system permitted if public sewer is C t. / —--__ , = available within 200 feet.) Installation will serve: Residence Commercial _ ther r Number of living units: Number f Brooms ` Character of soil to/a depth of 3 feet: r __ Water table depth SEPTIC TANK Type/Mfg _ r ''Capacity Q0_ No. Compartments PKG. TREATMENT PLT. El � / Method of Disp9sal ` Distance to nearest: I Well_�-_� Foundation . -A-6 Property Line c2s- _ LEACHING LINE ry No.j& Length of lines Total length/size Q I Qr FILTER BED ❑ Distance to nearest: Well �Q. Foundation�-QProperty Line SEEPAGE PITS 'L, Depth _� _Size X IRB lumber A1 C Property Line SUMPS Distance to nearest: Well-��y_'• Foundation * - DISPOSAL PONDS Cl 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. Homeowner 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 no© 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 compensate tion laws of California." The applicant t call fora quir d'inspections'Complete drawing-on reverse si Signed X_._. Title: _—__ Date L FOR DE ARTMENT USE ONLY o Applic ion Accepted by Date �L` 'L Area J-2- Pit or rout Inspection byDate Final Inspection by �.-�- Date7 6 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 95201 FEE AMOUNTDUE AMOUNT REMITTED CK RECEIVED BY DATE ! PERMIT NO INFO _ `_ CASH EH 1324 iREV 5; ) L4 9 O Ci o-1 t„C\5Z,