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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTAICT 1601 E., HAZEL T ON AVE., STOCKTON, CA r Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED I {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. 1662 for well/pump and the Rules and Regulations of the San Joaquin l Local Health District. Job Address l- 4C I --� City -7A Lot Size PM Owner's Name AddressPhone Contractor y��/ • /�� Address�I l��yT �� License fVoo-Z Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L] SYSTEM REPAIR LJOTHER 1:3 DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial L1 Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing 4 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f - Public �❑—Other - ° "C- Delta Depth of Grout Seal Type of Grout----- I rout -I I Irrigation __.Approx.'Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P: - t.ti State Work Done_ Well Destruction ❑ Well Diameter; '1 Sealing Material (top 50 . -.-- Filler Material (Below 50') -- Depth .� „rte,< TYPE OF SEPTIC WORK:;'NEW.INSTALLATIO REPAIR/ADDITION DESTRUCTION i I (No septic system permitted if public sewer is ; wr. # available within 200 feet.) Installation will serve: Residence '/ Commercial— Other 3 Number of livingunits: Number of bedrooms -41 \Wates table depth'`, .• ��- a Characteir of soil to a depth-of-3 feet:-- - ��-• �` Capaeit �` No Compartments SEPTIC TANK ❑ Type/Mfg ,, Y . i - - PKG. TREATMENT PLT. ❑ ! Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ` Total lengthlsiie r ^ d FILTER BED Distance to nearest: Well 2R Foundation/O f� Property Line .. SEEPAGE PITS I I Depth i Size _ Number SUMPS L) Distance to nearest: Well Foundation Property Line k 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 rules and regulations-of the San Joaquin Local Health Di§trio. 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 1 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 fallowing:"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." r �. The applicant must call fo all required inspections. Complete drawing on reverse side. Signed X— }•_ Title: ��dn3 moi Date: . t2,z FOR EPARTIMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Dai%�/� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 /+ Fill AMOUNT DUE. . rAMOUNT REMITTFl7 •. C K RECEIVED BY DATE PERMIT'NO - ._- INFO .K u r-EH 13-24(REV.r/R5) .J O/�O __�L 4 l 1426