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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED `T9 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct end/or Install the work hereln;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 4 .. moi.. Local Health District. cr t1 Job Address S City f •` Lot Size , - PM t Owner's Name Address /,5 7 5~7 A�� Phone Contracti79A:�C" i *t�'< �R Adidress Peg7% `'" Llcens�,No. -? 6o Phone 91 wld TYPE OF WELL/PUMP: j NEW WELL ❑ WELL.,AEPLACENIENT"❑' `r DESTRUCTION O PUMP-INSTALLATION ❑ i � SYATEM` AEPXIRfM �L , L OTHER O DISTANCE TO NEAREST: SEPTIC TANK ! _ SEWER'LINES 'DISPOSAL FED. PROP. LINE l FOUNDATION 4 AGRICULTURE WELL OTHER WELL,_ PITS/SUMPS -_ o INTENDED USE TYPE OF WELL j PROBLEM AREA CONSTRUCTION SPECIFICATIONS � 's O Industrial E_ Open Bottom ❑ Manteca Dia. of We11i'Excavation Dia. of Well Casing ❑ Domestic/Private O 6revell Pack O Tracy Type of Casing /7J Specifications «� O Public ❑ Other �� ❑ Delta 1111 Depth of Grout;Sedl -�� Type of Grout_ U't Irrigation -_._-Approx. Depth. C3 Eastern ) Surface Seal Installed by'� Repair Work Done C Type of Pump H.P. * ate Work Done— Well Destruction 13 Well Diameter _ Sealing Materria!Atoop.50') �'^� r }� Depth Filler Materialdf 611ow SO')_ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i] DESTRUCTION,[__)'.(No septic system permitted if public sewer is i -available within 2.00 feet.) Installation will serve: .Residence Commercial^ Other m — F Number of living units: "Nubaqd*roorTv.__c1a11_Character of soil to a depth of 3 feet* n • Wter table depth vSEPTIC TANK 41 Type/Mfg Capacity .DvNo. tmComparentsPKG: TREATMENT PLT.El l s r i Method of Disposal i Distance to nearest: Welf�_A 6 Foundation Property Line LEACHING LINE [?<No. &Length of lines f- U Total length/size w, i FILTER BED ❑ Distance to nearest: Foundation Property Line. SEEPAGE PITS .0�S- Sizes t 3 ft�umber SUMPS ❑ Distance to nearest: r Weli Foundation /40 Property Line_:5�7 _ _ j DISPOSAL PONDS ^❑ i ' 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 penton in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certlfles 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." j I f F The applica_ ust call for requyted inspeciions-Complete drawiin on reverse .side, -- - ---1 Signed Title: r Date: FOR DEPA TMENT USE ONLY ! -� - ---�,pplication-Accepted-by-' --` S r Grout Inspection by Date Final Inspection by 6it1 y ate i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6386 rApplicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk_, CA 95201 I � r i I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. + EH 1321(REV.)'85) b/�7 ( EH 14-M O•=�