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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-67.61 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .' (Complete in Triplicate). r 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: �p Job Address /1 Lry ; City �c Lot Size PM f # Owner's Name [.l C.%o � Address ��1 �"1 Phone Contractor lS. ��-sAddress N. W,lsoj wA License No. 6 y, Phone 6-919'0 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �. FOUNDATION AGRICULTURE WELLL�- OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial! ❑ Open Bottom ❑ Manteca t- Dia. of,Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack. ❑ Tracy f 4Type,of;Iasin t s + g Specifications 0 Public t ❑.Other kp Delta Depth of Grout Seal Type of Grout El Irrigation ___Approx. Depth 0 Eastern Surface Seal Installed by I Repair Work Done-„❑ Type of Pump H.P- 'State Work Dane Well Destruction' ❑ t Well-Diameter""""" "c"" Sealing Material atop 50'j Depthx �`�F Filler Material (Below 50') ?t TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 0' DESTRUCTION ❑ (Noseptic-system permitted-if public sewer is available'within 200'feet.i { f Installation will.serve': Residence,►' Commercial_ Other r r tF Number of living units: __L_ Number of bedrooms_ ° v Character of soil to a depth of.3 feet: L O- _ t rt i Water table depth SEPTIC TANK Type/Mfg a rh�rCf Gapaci l Z 186 CA L No.�c6ompartmentss9 3 PKG. TREATMENT PLT. ❑ Method of Disposal w l Distance to nearest: WeIIT�'l;Foundation ,Z / Property Line Z.o a LEACHING LINE No. & Length of lines 7 * r`�" t Total length/s��-3 - FILTER BED Distance to nearest: Well /O �, r �_ '.Foundation�_ property Line SEEPAGE PITS Do s� Jc" _Size NuJrlbar `< ' SUMPS ;00- flistance to nearest: { Well/D Foundation_ r>�/ Property Line � '1 t DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the workZill 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 intheperformance of the work for which this permit is issued,Fl 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." The applica ust call or all require inspections. Complete drawing o ir arse side. Signed - Title: v Date: / 7 L�' O DEPARTMENT USE ONLY r Application Accepted4 . Date7� r Area -�-' I Pit or Grout Inspection by Date Final Inspection by O' Date' %$"��/` I Ad nal Comments: .` y C r ; Stk 466-6781 - ClLodi 369-3621L1Manteca 823-7104 1.-❑.Tracy 835-6385 Or 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 INFO CASH RECEIVED BY+`- DATE PERMIT'NO. + EH 13-241REV-1/951 '/ f -1-7-Y7 ! v EH 14-28 ( U .. '^.4Yl Wim. ... ~7-Y 7 0