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i 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 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or in staEl 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. Ca i s Job AddressCity ize—{ w„�PM Z I Owner's Name b? Address Phone .�. Contractor Address . c , "`-`� 'License No.d7 1gf pho TYPE OF W L/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION-0_. SYSTEM-REPAIR-0— DISTANCE REPAIR"❑—DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL ✓� OTHER WELL PITS/SUMPS _ INTENDED USE r `TYPE OF.WEL�—L PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; ❑ Industrial - ❑ Open-Bottom\'--0-Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack'% ❑ Trac - Type ype of Casing_A Specifications ❑ Public 171 Other r E) Delta Depth of Grout Seal Type of`Grout ❑ Irrigation ---Approx. Depth ❑ Eastern,,;" Surface Seal Installed by Repair Work Done L Type of Pump `H.P. -'_0, State Work Done Well Destruction ❑ Well Diameter Sealing`Material (top 50') el Depth Filler Materia Below 50') U, TYPE OF SEPTIC WORK: NEW INSTALLATION ❑,rREPAIR/ADDITION L0. DESTRUCTION ❑ {No se tics N { .� 1 � p system permitted if public sewer is available within 200 feet.) Q Installation will serve: Residence`Commercial__F Other, Numb&of living u6iitsc • d,,—,N,mber of bedrooms ./ : - ~� r Character of soil to�a depth.of 3 feet: Water table depth_ 7 SEPTIC TANK i p Type/Mfg Capacity No. Compartments ; f PKG. TREATMENT PLT. ID r ` Method of Disposal s Distance to nearest: Well Foundation Property Liner s LEACHING LINE, ''' ��No. & Length of linesv .� Totallehgth/size A%4 !r R FILTER 8ED 9, ,Distance to nearesii`Well ! Foundation property Line l' e i SEEPAGE PITS ❑ Depth Size f 'Number SUMPS ❑ Distance to nearest: well Foundation ' .Property Line t ' DISPOSAL PONDS ❑ ' h I hereby certify that I have prepared this application and that the work will be done in accordence 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; "1 certify that in the performance of the work for which this permit is,issued, I shall not employ any person in such mariner 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 perfo�mance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws o nia." The appiic nt must c II for all r uire spectio .Complete drawing on reverse side. f k Signed Title: w Date: FOR DEPARTMENT USE ONLY Application Accepted by t Date Area- Pit rea Pit or Grout Inspection by DateFinal Inspection by Data Additional Comments: _ '`= ter ❑ Stk 466-6781 ❑-Lodi 369-3621 O`Manteca •823-7104` ❑ Tracy 835-6385 t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED 'RECEIVED BY DATE PERMIT NO. + EN -241REV-1/951 42EH 1I'J'd ' - / � 7—I