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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,:STOCKTON, CA ,, Telephone (209) 466-6781 1IPERMIT EXPIRES 1 YEAR FROM DATE ISSUED « 1 (Complete in Triplicate) k�f 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. 7 f� S Z C7 ' Job Address i! City Lot Size �O, PM 1 l i�' /�/( 'StZ Owner's Name 4 F A—�-"J ,��""�✓Address l Phone ; SL�", Address License No. Phone Contractor -- ( (\ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ " \I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK., SEWER LINES DISPOSAL FLD. PROP. LINE \ 't F, V FOUNDATION'. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL —PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom D','Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy; Type of Casing Specifications ` ❑ Public ❑ Other ❑ Delta `s ,'fDepth of Grout Seal Type of Grout El Irrigation ---Approx. Depth C1 Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 50'1 _r Depth. Filler Material (Below 50.)"E _ I ~ f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is 'available'wiithin 200 feet.) Installation will serve: Residence Commercial_ Other 1 Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ;c.rTypelMfgr ^4 �~ Capacity O O (� No. Compartments PKG. TREATMENT PLT. ❑ j �+ �..� .� J Method of Disposyl L Distance to nearest: Well Foundation Property Line — 4 LEACHING LINE J21 No. & Length of tines d Total length/size 1610 FILTER BED Distance:to nearest: Well _101—Fou ndation, t'Property Line fI SEEPAGE PITS ID Depth I Size Number SUMPS _ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 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." Contractors hiring or sub-contracting stgnature 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 applicanlmust call for_qII requ red inspections. Complete drawing on reverse side. ' _ .off /i�7'e�s Title:' tlol Date: •.1 Signed X FOR DEPARTMENT USE ONLY Application Acceptedby Date ` Area Pit or Grout Inspection Date Final Inspection by Date Additional Comments: I ❑ Stk 466-6781 ElLodi 369421 171Manteca 823-7104 ,O Tracy- 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. HazeltonfAve;y P.O.;Box 2009,Stk., CA 95201 FEEASH -AMOUNT DUE AMOUNT REMITTED RECEIVED BY ' DATE PERMITNO. INFO + EH 13-24 IREV,i EH 14-26