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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZELTON AVE., STOCKTON, CA ' l10 Telephone (209) 466-6781 f 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 welt/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �IT- 1 City `��lot Size _AC PM n Al Address ._ T�*--� -� C - Phone Distance to nearest: W_� Owner's Name _.I�,.-ley--I — - .. Contractor �_l,�y�L.- -- j^/sJ� License Na. 7�_-7..(,r Phone"fig dD Address�_�Q,_----_- ' _. - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ "SYSTEMIREPAIR ❑ OTHER F1 DISTANCE= TO NEAREST -.SEPTIC TANK �_ SEWER LINES _—_.,,DISPOSAL FLb. ___ PROP. LINE -: — FOUNDATION AGRICULTURE WELL _- OTHER WELL _PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- + El Industrial ❑ Open Bottom 1 ❑ Manteca - Die. of Well Excavation — _ Dia. of Well Casing ❑ Domestic/ Private 0 Gravel Pack ❑ Tracy Type of Casing ._ Specifications F'1 Public ..n Other f-1 Delta Depth of Grout Seal Type of Grout -- t I 1 Irrigation -..Approx. Depth I I Eastern Surface Seal Installed by —•- ----- '� _ State Work Done Repair Work Done ❑ Type of Pump � H.P. _.._ - -- — Well Destruction U Well Diameter Sealing Material (top 501- - Depth _ Filler Material (Below 501 _ r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR /ADDITION LI DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) f r Installation will serve: Residence ---_.. Commercial-_ ✓ Other _ fl Number of living units:. A Number of bedrooms 1 �*� (� y (; Water table depth e Character 'of soil to a depth -of 3'feet: _._ /�J_A �_ _-- f r SEPTIC TANK ❑ Type/Mfg -- P *!L _. — __ _ Capacity- 12-4?a Na. Compartments Method of Disposal PKG. TREATMENT PLT. L1 I 11A 4 F A-;- Propertv'Line I� el oun a I s LEACHING LINE L'r No. & Length of lines ___-..a "�"—Total length Fit -TER BED . ❑ Distance to n©crest: Well __Zffi-�. Foundation AAW Property Line Y SEEPAGE PITS Iyl Depth —Size / Number;. - SUMPS LRr Distance to nearest: Well Foundation __ _D_Q_._. , Property Line DISPOSAL PONDS ❑ U m P I hereby certify that I have prepared this application and that the work will be clone in accordance with San Joaquin county ordinances, state laws, and rules and reputations of the San Joaquin Local Health Di§trict. 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'Califomia. 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, F shall employ persons subject to workman's compensa- tion laws of California." ` The applicant must call for all required inspections. Complete drawing on reve&o side. • r. t, Data. Signed X ��V2; Title: // j3 i• _.._.- N -; FOR DEPARTMENT OSE ONLY '*.. Application Accepted by r�yC'�,------- . Date .L ---- --_ Aroa------ or Grout Inspection by _ Date --Y Final Inspection by-R� Dat_ Additional Comments: ❑ Stk •466.6781 ❑ Lodi 369-3621 ❑ MantelIca 823-7104 ❑ Tracy 01 B36-&385 Applicant • Return all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED' CASH RECEIVED By DATE PEHMIT'NO. INFO ..- t.EH 13-24 IR EV. I n5 EH 14-20