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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ice" 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. Job Addre T «fes i City G a�� Lot Size PM �• C�f��ST�lSF!% Address 2 Owner's Name '0;!9- Contractor � Address 3�k0 eiOW fe Lit No. C Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ [f1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LlIndustrial C1Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface'Seal Installed bV% 1 Repair Work Done © Type of Pump H.P. State Work Done f Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence{! Commercial_ Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: ,�' d - Water table depth SEPTIC TANK &,-Type/Mfg C0;_0yC•00? Capacity Z2� No. Compartments �-- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well S� Foundation Z� Property Line f 34 LEACHING LINE No. & Length of lines Total length/size Z G docs7 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS WDepth Z 5' Size 33 //y, --Number 3 SUMPS ❑ Distance to nearest: Well Foundation r Property Line %2� r DISPOSAL PONDS I❑ 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 c fy 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 c ired ' specti omplete drawing on,reverse side. �� Signed Title: �v�''f 7`�` Date: �� 3 C;~` jS FOR DEPARTMENT USE ONLY ` Application Accepted by Date S" —Z75-- Ar it Grout Inspection by Date /Q Final Inspection by Date -� Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all co ies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEECK 0 IO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY D�ATEy PERMITNO. EH 241RE .t/65l � /(J53 EH 14-26