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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT - 1601 E. HAZELTON AVE.,aSTOCKTON, CA f Telephone {209) 466-6781 pM PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , , ...w (Complete in Tri licate)== . A � i1� -7�Pn� a 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 1 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 �13 `S City Frra 6 Lot Size PM y Owner's Name ��/�S� , J��1 Address J/ Phone �G ,� W n:,.. Contractor �' �-•� �. ddress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ INSTALLATION.❑.. .-'._ -"—•'-'°"SYSTEM REPAIR"El `""�'6" OTHER ❑ DISTANCE ST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE_MXdNQL �• , TION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF,WELL BLEM AREA CONSTRUCTION SPECIFICATIONS } � ❑ Industrial ❑ Open $ottom ❑ Mantec Dia. of Well Excavation Dia- of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type Specifications ❑ Public D Other ❑ Delta Depth of Grout Sea Type of Grout i ❑ Irrigation ----4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 50') Depth Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is El. l., available within 200 feet.l r Installation will serve: Residence Commercial_ Other f Number of living units: Number of bedrooms 4 I Character of soil to a depth of 3 feet: � Water table depth SEPTIC TANK ❑ Type/Mfg X I S+1 n,cq capacity Z No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i t Distance to nearest: Well Foundation r Property Line r LEACHING LINE 16 No. & Length of lines j � 40 L L, Total length/si e' U (--•�-- x[ FILTER BED ❑ Distance to nearest: Well iOD Foundation Property Line, i. SEEPAGE PITS ❑ Depth /d Size yk Number SUMPS Distance.-to nearest: Well + Foundation Propertyj ine i; j DISPOSAL PONDS ❑ !' R 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 i y; rules and regulations of the San Joaquin Local'Health District. 44.1 . I f ",.I - Home owner or.''licensed.agent's signature certifies ihe.following:"I certify-that in the performance of the work for which this permit is issued, I shall not a 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 applican u t call for all required inspections4Complate drawing on reverse side. f - 3 Signed 1 Title: J C>lV Date: FO DEPART ENT USE ONLY Application Accepted by Date ` Area p Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 36973621 "O 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 FE._.E _. AMOUNT DUE AMOUNT REMITTEDCK RECEIVED BY DATE PERMIT NO. j INFO /�//�� t + EH 13-24{REV. i n s7 `[f` ! V' �� EH 14-16