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APPLICATION FOR PERMIT QUIN LOCAL HEALTH DISTRICT .- SAN � 1601 E. HAZEL T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 _ ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED if 06 -05'(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. �j �7 Job Address ul �J / 5 ilE, G,,-,T,, /yc" -.— CitySC- l ani_ Lot Size PM Owner's Name / rr j'�t r i wC Address 3 75 . �. C y}r Tt� �� Phone �'"-373 P().r r9 ��7Lfl TrFv.cf cense No ��708� Phone �7N-�f64, Contractor l%a"rn1 �*cN�ac Address T"E OF.WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ Ffi f OTHER ❑ DISTANCE TO NEA SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FO i PITS/SUMPS AGRICULTURE WELL OTHER WELL INTENDED USE TYPE . WELL P-ROBLEM AREA'—CONSTRUCTION SPECIFICATIONS © Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing I] Domestic/Private ❑ Gravel Pack ❑ Tracy Typ using "'� `` Specifications ll Public n Other ❑ Delta Depth of Grout�`ea '% *Type of Grout I I Irrigation --Approx. Depth l 1 Eastern Surface Seal Installed by f - Repair Work Done ❑ Type of Pump H.P. State Work;gone Well Destruction ❑ Well Diameter Sealing Material Itop 501 ` Depth Filler Material (Below 50') .` ?TYPE OF SEPTIC WORK: NEW Ify�TAt�LAN TIOREAIR/ADDITION I I DESTRUCTION) 1 lNo septic system permitted it public sewer is IYYy�t Uf d rVU w-,- available within 200 feet.) 1 t Installation will serve:' Residence r l�• Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK IX Type/Mfg 1 Capacity v r.a oo No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well /SO � Foundation� Property Line � 3 LEACHING LIN_ E EV No. & Length of lines Total length/size 17,9 �� Q FILTER BER ❑ Distance to nearest: " Well V._ Foundation Property Line ?— I t f SEEPAGE PITS IX Depth _ �2 Size 33 k Number �- i t SUMPS Pr Distance.to.nearest: Well Foundation Property Line U DISPOSAL PONDS ❑ t 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 r 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, 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 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." The applicant must call for all required inspections. Complete drawing on reverse side. r� Signed X Title: W rV Date: FOR DEPARTMENT USE ONLY 7 n Application Accepted b 16t `' ' Date �Z w Area Pit or Grout Inspec y ~Da Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca,/823--74-64 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 Ary, i FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERM17'NO. INFO CASH E r + EH Q-24(REV.f/H 5) EH 14-n l