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t --a y _ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephohe (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hepeby 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 City Lot Size PM Owner's Name(a_Z,416, I Address 7>v /, ..__ Phone /T2%2 Contractor Address 5 icense No. Phonef"?` '! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ _SYSTEM;REPAIR.❑ OTHER ❑ DISTANCE.TO NEAREST: SEPTIC TANK SEWER L1_14E5 DISPOSAL FLD r PROP. LINE FOUNDATIbN AGRICULTURE WELL' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing . ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications \ I Delta Depth of Grout Seal Type of Grout I I IrIrrigationAppr ^� Public ❑ Other ❑ ox Depth l I Eastern Surface Seal Installed by- � Repair Work Done ❑ ' Type of Pump H.P. u State Work Done _ ` Well Destruction ❑❑ Well Diameter Sealing Material atop 50') Depth '1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR)ADDITION l 1 DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) 46— Installation will serve Residence Commercial_ Other r � !Number of living units Number of bedrooms _ Character of soil toea depth of 3 feast, table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PI-T.'[3if Method of Disposal - � Distance to nearest: Well Foundation Property Line LEACHING LINE Y❑ No. & Length of lines Total length size ' Tis FILTER BED ❑ Distance to nearest: Well Foundation Ap, Property Line SEEPAGE PITS b f 1 Depth"f - ""Size � Number SUMPS ` SUMPS L] Distance to nearest: Well Foundation 'Property Line j DISPOSAL PONDS ❑ I j 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 Di§trict: Home owner or licensed agent's signatufe certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not t employ any person in such manner as t&become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in thi'performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applic u call for all required inspections. Complete drawing on reverse side. Signed X � � Title Date: FOR DEPARTMENT USE ONLY ` Application Accepted by VP1U1CIL _. Date .Area Pit or Grout Inspection by 11 Date Final Inspection by Date 16 Additional Comments: Y ? ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2OW, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. +.EH 1 -24(REV.1iH5] EH 144-28 Li-301, &.27-1