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APPLICATION,FOR PERMIT SAN JOAQUIN LOCACHEALTH DISTRICT 1601 E. HAZEL T ON-AVE_ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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., „ Job Address ! 71 �?Y� ZjIL) U.0 I Y City Lot Size PM Owner's Name Address Phone Contractor Address) Jlf i47(1/ License No. Phone, TYPE OF WELL/PUMP: ► NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other ❑ Delta Depth of Grout�S6551 Type of Grout I'l Irrigation `_Approx. Depth I-1-Eastern•_ - Surface Seal Installed by - Repair Work Done ❑. Type of Pump -- H.P. State Work Done _ Well Destruction ❑=; ;Welf Diameter u Sealing Material {top 501 Depth + +Filler Material (Below 501 { TYPE'OF SEPTIC WORK: NEW INSTALLATIOPV, REPAIR/ADDITION' DESTRUCTION I ].(No septic system permitted if public sewer is S 1 i } available within 200 feet.) Installation will serve: Residen_ce�Commercial Other Number of living units: t Number of bedrooms Character of soil to a depth of 3 feet: bo7 G e __-Water table depth SEPTIC TANK '., ❑ TypelMfg L• CapacityNo. Compartments t PKG. TREATMENT PLT. ❑ .�., € Method of Disposal , ',Distance to nearest: Well A7_>? Foundation Property Line . • G LEACHING LINE No. & L gth"of lines CT Total length/size- 4- ength/size "FILTER BED ❑ Distance to earest: Well ./�-TF FoundationST Property Line " � � e ,, a �• f r T SEEPAGE PITS 11 Depth { Size ' } Number SUMPS Ll Distance to nearest: Well �" Foundation` { 'Property Line DISPOSAL_ PONDS ❑ 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 Districts--�* Home owner or licensed agent's signature certifies the-following:0 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'subjecf to workman's compenption,laws of California."Contractors hiring or sub-contracting signature I 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." r The applicant must call for Ilrrequir inspectiorRs. Complete drawing,on reverse side. ^ ' Signed Xw _ ��r a-.-C/`u Date: _'Title:-- �r .01 r' ,.r`w °^ .yam. ` -Y FOR DEOARTAAENT-USE,ONLY.- 't. 4sti � 'w y Application Accepted by _ `"� t Date 'Z p Araa t. i 'Pit or Grout Inspection by � Date Finahlnspection by �• '"-�"""`� ' Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 tO Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Parmit7Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE _'A PUNT„REMITTED,_„ CK REMVED_BY...� „-OAT _ PERMIT_NO. INFO « 4-CASH^+ a + EH13-24(REV.i/85) (f-' EH 14-26