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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y (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. Job Address / /1 rpt/ _rCity Lot Size PM Owner's Name Address !' y�_,�j1 y ! �/ , Phone Contract Address �7KJLicense No- 2_1S22t0 Phone. ��S I�•� TYP OF,WELL/PUMP: NEW WELL ❑ ,WELL REPLACEMENT L1 DESTRUCTION ❑ — -� -PUMP-ITALLATION-'O` SYSTEM-REP-AIR ❑ OTHER ❑ DISTANCE TO NEARES .: . _ C TANK SEWER LINES DISPOSAL FLD.__ PROP. LINE '-FOUNDATI_ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE-OF`WELL �PROBL A CONSTRUCTION SPECIFICATIONS C Industrial ` "> -CJ Open Bottom ❑ Manteca .R Well Excavation ��- �. - Dia. of Well Casing A ` Dom stt3 iclPrivate ❑ Gravel Pack ❑ Tracy Type of Casin _ Specifications y 1`1 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation __Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump f H.P. _ State Work Done ' Well Destruction ❑ Well Diameter Sealing Material Itop 501 _ Depth Filler Material (Below 50) TYPE OF SEPTIC WORK. NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION 1 1 (No septic system permitted if public sewer is r , . available within 200 feet.I Installation will serve: Residence_ Commercial + Othe Number of living units: Number of rooms Character of soil to a depth of 3 feet: Water table depth s SEPTIC TANK 16d' Type/Mig _ + Capacity0 _ 'No. Compartments PKG. TREATMENT PLT. ❑ f r Method of Disposal 7 Distance to nearest: Weil _i Foundation _ 10 Property.Line LEACHING LINE CI Nd- 8 Length of lines Total length/size t _ FILTER BED___..;._._p^Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation __ Property Line ' DISPOSAL PONDS ❑ -- 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, andlo rules and regulations of the San Joaquin Local Health District. _ Home owner or licensed agent's signaiu�e ce`rlifii§s--the following:-'I-certity that in the performance of the work for which this permit is issued, I shall not employ any person in suohmanner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the folbwing:_I ce ify 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. The applicant u call forall it ''nspectionrs. Complete drawing on reverse qsid,. (1Signed X_ Title: P DI ate: FOR �EP'ARTMENT USE ONLY Application Accepted dy. Date Area Pit or Grout Iris °s: - p` n. ectioby'"^ �: '—'r "Date` � Final Inspection by Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Haalth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 9Y DATE PERMIT'NO. INFO CASH . EH 17-26(REV,iHsi �O EH 14.2e 70^c� - �37a 8 .�