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4fi y x APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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, �� ttL1.. �.n .�•� I Job Address _._ r_.,,__..SL7ti. µ%� � 1� City.�+L�`' _� Lot Size `-� PM .j��'19-y Irl ry`�•�,GSr-�" _ .^ _— ..__...... _ _ UOwner's Name NVI Contractor ��,,�� _ Address License No. Phone TYPE OF WELL/PUMP: NEW WELL G ^ WELL REPLACEMENT 2DESTRUCTION C _ — PUMP INSTALLATION 0 SYSTEM, REPA OTHER 13 DISTANCE TO NEAREST: SEPTIC TANK ...... SEWER LINES DISPOSAL FLD. PRDP. FOUNDATION AGRlCUL WELL OTHER WELL. ISUMPS ...-,._ ...._._._.._..__ _.�...._.._...._ _. ,_... .. INTENDED USE TYPE OF WELL PROBL. REA CONSTRUCTION SPECIFICATIONS « 0 Industrial 0 Open Bottom anteca Dia. of Well Excavation_ Dia. of Well Casing W Domestic/Private C Gravel Pac C Tracy Type of Casing...,,._ _. Specifications '"I Public n Ot P, Delta Depth of Grout Seat Type of Grout _ I I irrigation _ Approx. Depth 1 1 Eastern Surface Saar!ins ad by_ _ Repair Work Don a Type of Pump H.P. _. State Work Done Well Desrr n Well Diameter Sealing Material(tap 50') Depth �..__ ..__ Filter Material (Below 501 ...... _....---- TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 ; DESTRUCTION ; 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence .__ Commercial Z Other Number of living units: __L7 Number cf bedrooms—+'_..__ ✓'� Character of soil to a depth of 3 feet: __...__ _....__....._.._,_ .__., Water table depth SEPTIC TANK X Type/Mfcj L 1J� —...._......__. g ._. -- Capacity...�f� No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well__ Foundation.._.__.._.'_..._ Ptopeny Line_ LEACHING LINE ��" No. &Length of lines _._.6_..... -..,,Lllb _. Tot'al length/size � FILTER BED C Distance to nearest: Well __...... Foundation Property Line ....._ __._....._ .................. SEEPAGE PITS 1 ! Depth _.... .Sias _ Number ..._....._ I` SUMPS Ll Distance to nearest: Well_ Foundation_ Pr6perty Line DISPOSAL PONDS 0 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 pertormance of the work for which this permit is issued,i shall employ persons subject to workman's compensa- tion taws of California." The applicant m4st call lor_>�it r d inspections. Complete drawing on revem side, y Signed X /�/ a • _----e�r�----_............._.... TiUe:..__s=�zL��..__� OR DEPARTMENT USE ONLY Application Accepted by _. Date_ "'i11 a Area '�✓ Pit or Grout Inspection Dere_ Final Inspection by Additional Comments: t1 t (,,C ` d,L r v.�� fit.•' L)Stk 466-6781 C Lodi 369.3621 C Manteca 823.7104 C Tracy 7835-&385 Applicant - Return all copies ta: Environmental Has" Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PEftM1T Na. INFO r.fN14-2i1REV4-26 -CHI . - ) 10 l