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7J��. )iAPPLICATIONFOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRfCT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6791 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. �� G 1 e / <t cit / c:�� Job Address >6 Lot Size �. PM Owner's Name �+ AMOUNT DUE _ Address Phone ContraClor :��! �'/�'U Address ' ti ` License No:�Phone _ TYPE OF WELL/PUMP: EW WELL D WELL REPLACEMENT LJ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 I'��-- FOUNDATION AGRICULTURE. WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E] Industrial D Open Bottom U Manteca Dia. of Well Excavation Dia. of Well Casing i_I Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i i Public 1-1 Other f-1 Delta Depth of Grout Seal _ Type of Grout i I Irrigation _._ Approx. Depth i 1 Eastern Surface Seal Installed by _ Repair Work Done IJ Type of Pump H. P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION cr REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 teat.) Installation will serve: Residence Commercial , Other Number of living units: % Number of bedrooms � Character of soil to a depth of 3 feet: �QL7��9 s,2rl --Water table depth r SEPTIC TANK D Type/Mfg 24r3'%lekdt I__ Capacity.�/�J — No. Compartments —74 PKG. TREATMENT PLT. L1 Method of Disposal Distance to nearest: Well &X5 _ Foundation-ZLL_'Property Line g>Q vl— LEACHING LINE Ll No. & Length of lines — 7 �f g Total length/size �.c FILTER BED D Distance to nearest: Welt Foundation s Property Line 46 / SEEPAGE PITS •P4•, Depth Size __ S N mbar SUMPS LI Distance to nearest: Well /'rd , Foundation _Z U 20- Property Line DISPOSAL PONDS ❑ --r ��••• : •••4. 1 „a.a P—Pasou tins appncalton 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 Diktrict. 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 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant�r ust call f all requ!rpd inspections. Complete drawing on reverse side. Signed X Title: ��''�Date: l'C/ 7 �2 FOR DEPARTMENT USE ONLY G // ' c Application Accepted by (f'Y� Date L tT gree i Pit or Grout inspection by Data /I, ri %if Final Inspection by Date Vii! %r.•; 5 Additional Comments: LJ enc 466.678! L.l Lodi 369-3621 0 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 95201 • EN 13-241REV. s��s7 EK 14.26 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. �'- 1 I'��-- n`� (.1