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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) Appficaiioh 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 Addresa -/ 6/ C0YYA4 Hp L><OfA/ AP-J, City Lot Size PM { Owner's Name 4 L . FVo1Mo`;444s Address Pfs' 'f' Phone t Contractor �f ti BiY �/JneV Address 6Q� 15L c•�4 �.1� +�. T[ icense No. � l Phone i TYPE-OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT_ ❑ DESTRUCTION D f{ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other n Delta Depth of Grout Seal Type of Grout I Irrigation _-Approx. Depth l I Eastern Surface Seal Installed.by- _ Repair Work Done ❑ Type of Pump H.P. f State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50')-4' Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION LA REPAIR/ADDITION l I OESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) "Installation will serve: Residence_ Commercial_ Other /fOb iL Ne04 Number of living units: 1 Number of bedrooms (� { Character of soil to a depth of 3 feet: I_0 Water table depth + j SEPTIC TANK 0 Type/Mfg �ji� �i3S/:_-_ Capacity-L&00 No. Compartments X- ` j PKG. TREATMENT PLT. ❑ +. r F.�. ,� , - ,� t �+, Method of Disposal t Distance to nearest: Well �z Foundation ✓o Property Line LEACHING LINE QI No. & Length of lines' "p Total length/size f SO x FILTER BED ❑ Distance to nearest: Well 94 z Foundation .9'9 Property Line {r SEEPAGE PITS I I• Depth Size Number ? SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ w 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. f = 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, I shall employ persons subject to workman's compensa- tion laws of California." r' The applicant must call for all required inspections. Complete drawing on reverse side. Signed ! Title! Date: O— S-- ,98 S FO D RTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by DateL � r 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 A INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMlCK i TNO.. 1 16�� r.EH 13-21 IREV.tin5l EH 11-29 4 1