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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA % x Telephohe (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) s 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. z Job AddressCity A Lot Size 2 PM Owner's Name� 9 Address 3 "� Phone ~ r P��71� ` 328 Z Z�P 3(08 Se dS" Contract r Address t 7 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ -WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i 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 i ❑ Domestic/Private ❑ Gravel Pack —El.Tracy.,r._Type.of Casing Specifications ❑ Public ❑ Other ❑.Delta Depth of Grout Seal- Type of Grout _ I I Irrigation --!.Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done Ll Type of Pump - -'H':P: -� State Work Done _ h Well Destruction ElWell Diameter Sealing Material 04—50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTAi-LAT10N REPAIRlADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feed V Installation will-serve: Residence Commercial_ Others Number of living units: Number of- Brooms �~ Character of soil to a depth of 3'feet: ` +` water table depth f V SEPTIC TANK '>ii6 Type/Mfg r" Capacity `1060 No. Compartments PKG. TREATMENT PLT. ❑ _�. ` f Method of Disposal -� r Distance to nearest: Well L ._....� Foundation 0r Property Line LEACHING LINE"" No. & Length of lines dotal length/size x FILTER BED ❑ Distance to nearest: Well ..iib Foundation _k_(�-_..--_— Property Line .` ) r w SEEPAGE PITS X Depth Size 1� X Number. 1 SUMPS LI Distance to nearest: Well Foundation ir7 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 Di§trict. 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, I shall employ persons subject to workman's compansa- tion laws of California." f The applicant must 11'for all r ed i t. s. Complete drawing on reverse si N Signed X Title: ; Date: FOR DEPARTMENT USE ONLY Applic 'on Accepted by Date r Area orf Grout Ins cti� by Date k/M Final Inspection by Date/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 LI Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO; CASH +.EH 13-24(REV.I?n 51 EH 44-29 Q