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M 1 APPLICATION FOR PERMIT I 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 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. ' t Job Address dg e'//w zrnw City JF5Cy046 eA'O' Lot Size PM ` F# f Owner's Namefl✓ COyY�'r.� Address Phone Contractor 1/So { Ste// Address License No. Yyf/-89� Phone_ �. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION El k ;`• _tea PUMP INSTALLATION 11 SYSTEM REPAIR ❑ OTHER C1I. 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 } ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i (I Public 11 Other i i ❑ Delta"` "-Depth of Grout Seal Type of Grout _ f" �.. I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done C] Type of Pump H.P. -State Work Done_ I - - Well Destruction ❑ Well Diameter Sealing Material (top 501 ' ` Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is '`R I .i available within 200 feet.l I - I ' Installation will serve: Residence_%, `Commercial_ Other � Number 5of living units: A Number of bedrooms 6 r Character of soil to a depth of 3 feet Av-f S,&At1 _Water table depth f SEPTIC TANK JA Type/Mfg aE'"G)s7- ., ° Capacity A 00 No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to nearest: Well � Foundation V0 Property Line 100 LEACHING LINE No. & Length of lines 3 9d xa t Total length/size .7-P, FILTER BED ❑ Distance to nearest: Welt rFoundation . Pro ert 'Line_. ii SEEPAGE PITS I Depth 'I. Size "• Number SUMPS yT Distance to neatest: Well � O' Foundation X`' Property Line DISPOSAL PONDS p `` • �- I hereby certify that I have prepared this application and that the work will be done in acc6tclance with San Joaquin county ordinances, state laws, an 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,.)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 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 required inspections. Complete drawing on reverse side. Signed X Title: Date: '3 1r r h FOR D_§PARTJKANT USE ONLY Application Accepted b ✓ v pp P Y � date Area Pit orr.Grout Inspection by Date Final Inspection by Date r..# Additional Corn Monts: ❑ St0466-6781 ❑ 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 2009, Stk., CA 95201P INFO AMOUNT DUE I AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. FEE - i + EH 13-24(REV.t/n 5) � EH 14-28 — / ' O