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' APPLICATIOhr FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA w j Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 Addressi- ,V— �� ' City TYe-y Lot Size PM ` Owner's Name oh/y r 'f Ot?Y a Address 1 � _A�� 3Y- 4%C7AO A Phone 9 32 Contractor 14IV r © 4 Address LOo.Z 94v r✓�V Auz'' License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 11 PUMP INSTALLATION ElSYSTEM,REPAIR ❑., - - - - R OTHER. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION 'AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL L,,= PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy. q Type of Casing Specifications FI Public C1 Other {-1 Delta Depth of Grout Seal Type of Grout _— I I.Irrigation t —Approx. Depth I 1 Eastern Surface,SealInstalled-by Repair Work Done ❑ Type of Pump H.P. State Work Done _ y} Well Destruction ❑ 'Well Diameter Sealing Material.(top 50'1 Depth Filter Material (Below 501)' M - TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION DESTRUCTION I 1 (No septic system permitted if public sewer is y available within 200 feet.) � Installation wilt server, Residence_L_ Commercial— Other Number of living units: _Number of bedrooms -3 Character of soil to a depth of 3'feet:. Ag" F Water table depth R jr SEPTIC TANK f�C�/"Type/Mfg_�y&" Arr GpAr' Yf� Capacity No. Compartments Z l PKG. TREATMENT PLT.,0 �� Method of Disposal - ,Distance to nearest: Well tY,q� Foundation I� Property Line 5"" LEACHING LINE ❑ No. & Length of lines Total length/size �1 D FILTER BED 91 Distance to nearest: Well�� _ Foundation Property Line SEEPAGE PITS * 11 Depth Size •� b� Number SUMPS Ll 'Distance to nearest: Well Foundation Property Line r � � 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. Horne owner or licensed agent's sigriature'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 compensa- tion laws of California.,' t I The applicant m t call for all required inspections. Complete drawing on reverse side. r.' Signed X ' f �I Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �Q Area II l ti Pit or Grout Inspection by Date Final Inspection by ate Additional Comments: ` O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 71 0 Tracy- 835-6385 n Applicant - Return all copies to:-Environmental Health Permit/S ' e 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ` -7/1-7 A'r'- O AMOUNT`OOEdeJA. MFO! �T REMITTED` CR RECEIVED BY 7 D//ATE GZ p .�PER�MlfIT�LfN. O. I., + EH 13-24 1REV.1/951 707) L7U' I3S'Al�-{7� Ek 14-2e v r �