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i APPLICATION FOR PERMIT i , ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I. (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. �o I Me, I R� f Lot Size - � { Jab Address City 1 PM t _ ` Owner's Name S Address SR Phone f Contractor 1.ce Address 0 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑'` t',WELL REPLACEMENT-0V DESTRUCTION ❑ r - - PUMP lNS"TAL-LATION D SYSTEM-REPAIR OTHER._❑. :_ -•_ __� _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE" FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ! Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQN L i rq ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of-,Well Casing �+ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r j'l Public ❑ Other n Delta Depth of Grout Seal Type""of Grout ,I Irrigation YY� —_Approx. Depth l I Eastern j. 5urfaca Seal Installed by hS Repair Work Done ❑ Type of Pump H.P. i { State Work Done t ' V611 Destruction ❑ Well Diameter Sealing Material atop 50') $ fi Depth Filler Material IBelow 50') - 1 { TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) t Installation will serve: Residence�Coritmercial Other rNumber of living units: Number-'of bedrooms .___ ' Character of soil to a depth of 3 feet: s.t Ld Water table depth t Y SEPTIC TANK Type/Mfg Capacity .- i No. Compartments —' ISG."TREATMENT PLT. ❑ i i Method of Disposal t Distance to nearest Well_-t0-0'_ Foundation~ Property.Line t? LEACHING LINE �No. & Length of lines _ 70 "" Total length/size V 1 FILTER BED ❑ "' Distance to nearest: Well E � Foundation f{fir` Property Line 1 " s�.�..,...,.-.�,..-......� ._..�..-.�-�—.,�---.mow,..-,."--s,..,�._.,..�•...� _ _ .. K SEEPAGE PITS I 1 Depth Size _ Number F SUMPS ❑ Distance to nedrest: Well 'Foundation Property Line DISPOSAL PONDS ❑ t " Hereby certify that I have prepared-thisiapplication.,'6d'that the work will be done in accordance with San Joaquin county(ordinances, state laws, arid rules and regulations of the San'Joaquin Local Healih.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"Ca'lif-dr'hla."Contractor's hiring or sub-contracting signature i certifies the following: "I certify that in the per(orma)lce,of the work for which thrs,;permit is issued,1 shall employ persons subject to workman's compensa- I' i tion laws of California." 41 The applicant must call fo all requir I pectlon`s +Complete drawing on reverse side. / g f I }" Signed'Xµ«� Titie: ��' µ� Date: FOR DEPARTMENT USE ONLY P " Application Accepteded b7y Date Area 1 Pit or Grout Inspection by Date Final Inspection by Date�IF Additional Comments: M ❑ Stk 466-6781 ❑ Lodi 369-3621 CI Manteca 823-7104 ❑ Tracy 835-6385 j Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201- FEE 5201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY 4 " DATE PERMIT No. +.EH 1344 F • EH 14-2e