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APPLICATION FOR PERMIT J.= 0-11, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA r Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM ©ATE ISSUED (Complete in Triplicate) I: � Application is hereby made to the San Joaquin Local Wealth District for a permit to construct and/of 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 � City - �— Lot Size PM D �v�� ✓l�t'YL O [� �� Phone (7'� Own �,,� er's Name Address // Contractor Sef Address License No. Phone { E OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR❑ OTHER ❑ DISTANCE EAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLPJISIS1�iVT r INTENDED USE TY WELL PROBLEM AREA CONSTRUCTION SPECIF.IGAT-to S , 1:1 Industrial ❑ Open Bottom Manteca Dia. of xcavation Dia. of Well Casing ❑ Domestic I Private Ll Gravel Pack ❑ Tracy ype of Casing Specifications 171 Public F1 Other elta Dep rout Seal Type of Grout—.-- _ L-- I I Irrigation' --A epth I.) Eastern Surface Seal Inst �^ - QJ Repair Work Done ype of Pump eH.P. State one Well Dest ction ElWell Diameter Sealing Mat4ial-ttop 50„ Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIRlADDITION I it DESTROVION INo septic system permitted if public sewer is F-- --~ -x- ----^ -• { available within 200 feet.I f h Installation will serve: Residence— Commercial ..— Other ri Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal t Distance to nearest:` Well ----`Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well dd 7R11(\y ,y Foundation - 1-. Property Line SEEPAGE PITS I 1 Depth 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, 1 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 compensa- tion laws of California." i r The appli ant must call for all required inspections. Complete drawing on reverse side. x Signed X Title: Date: / FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspectio Date / Final Inspection by - - ,f& Date 7 l 8 Additional Comments: lev — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE fPE�AMIT'NO. INFO +.EH13-24IREV.+ x51 � ]� U`� C"" EH 14-211