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APPLICATION FOR PERMIT 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) �� J 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. G } Job Address 6 71? City AgALot Size 4� PM r Owner's Name 1215 Address_7 - Address �t� 2 37, /.1 &T.. ... Phone s A- Contractor's Name �.0. -/,o j4114 E ? License No. 4— ?.T�',2 Phorte o2 // TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANKTSEWER LINES DISPOSAL FLD. PROP. LINE J FOUNDATIO&I AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 04 INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS - ❑ Industrial ❑Open Bottom { IJManteca Dia. of Well Excavation Dia. of,WWI Casing s ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ` ❑ Public ❑'Other ❑ Delta I Depth of Grout Seal = Type of Grout ❑ Irrigation JApprox. Depth ❑ Eastern Surface Seal In by Repair Work Done ❑ Type of`Pump H.P. State Work Done �t Well Destruction ❑ Well Diameter Sealing Material (top 50') ✓, S i Depth Filler Material [Below 501. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r A r _ available within 200 feet.) Installation will serve: Residence_ Commercial_ Other-'UA Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity / eye 64L No. Compartments w a PKG. TREATMENT PLT. ❑ w- .�.. �.+ '� �- „y,,� Method of-Disposal Distance to nearest: Well Foundation 4D' Property Line LEACHING LINE No. & Length of lines �� Total fength7size r �} &a:lf - _._ Property Line ®Q FILTER BED ❑ Distance to nearest: Well Foundation SEEPAGE PITS ❑ Depth J" -Size' `-� dumber SUMPS N!' Distance to nearest: Well /tD Foundation Z Property Line v d 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, and .F 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 ftp 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 compensa- tion laws of California," The applicant must call for all r ired i spections. Complete drawing on reverse side. Signed ' Title:' Date FOR DEPARTMENT USE ONLY / q =p�tio;1 Accepted by Date !1 f �/� t� Area At-or Grout Inspection by Date / Final Inspection by, Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3511 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601-E. Hazelton Ave., P.O'. Box09 20 , Stk., CA 95201 =�, INFO AMOUNT DUE AMOUNT REMITTED _ CASH RECEIVED BY DATE' PER MIT''NO.- 9, .:_.�.. EH 14-28 't S ,� -- - - +17/ 1 3I�f_ oil ! �Y� �