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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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 Address -�r�r?O C7► rs�'�AK 1�G/ City_-77-,lS/ Lot Size PM Owner's Name C-14W7 Y 6t&6 Address Phone Contractor Ai DN Address dA0.7 �L G° �}✓e License No. yyy "891 Phone I'I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (tom INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing• Specifications I1 Public n Other ❑ Delta Depth of Grout Seal* Type of Grout -.- I I Irrigation ---Approx. Depth I i Eastern Surface Seal installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR)ADDITION X DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence___- Commercial— Other CLV & /-Ie&S-C Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Lidbr 40,4e1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity `' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines __ /tea X 36 Total length/size 3�r7 FILTER BED ❑ Distance to nearest: Well r1 Foundation /ad Property Line SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation ` _ Property Line DISPOSAL PONOS ❑ 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, 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant mut call for required inspections. Complete drawing on reverse side. - Signed X� e . . Title: Date: y /9 -OVNIZ9 F D RTMENT USE ONLY r �9 Application Accepted by Date ,y fly Area _!_ ___- a = Pit or Grout Inspection by Date Final Inspection by � ��' � Date Additional Comments: jl l� ❑ Stk 466-6781 b Lodi 369-3621 ❑ Manteca d3-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services-1601 E.'Hazelton Ave., P.O. Box 20W, Stk., CA 95201 T � _ FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'NO. INFO- ASH / JI + EH 13-24(REV.tiH5) -76 `7 / EH 14-26 O� [Q`�� •