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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ► PERMIT EXPIRES TYEAR FROM DATE ISSUED r ' (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. r Job Address Cr(7 R ,q CityLot Size + Wpr tr / r. Owner's Name 1 1 Address Contractor Address _� 3o" License No.�J6 /3cl,3 Phone' TYPE OF WELL/PUMP:?-; tpw NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR_❑ C OTHER ❑ ¢ DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES ' DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL py PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial 1 ❑ Open Bottom,s "t❑.Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private t ❑ Gravel Pack k ❑ Tracy Type of Casing Specifications 171 Public # F1 Other Cl Delia Depth of Grout Seal Type of Grout I Irrigation —.Approx. Depth'y l I Eastern 1 I Surface Seal installed by - 1 Repair Work Done ❑ Type of PumpH.P:, State Work Done jj Well Destruction ❑ Well Diameter ' Sealing„Material (top 50') ' J _ "I'll - Depth "K t Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Wit REPAIR/ADDITION'f,I L,DESTRUCTION l i,INo septic system permitted if public sewer is available within 200 feet.) 1 r n1 Installation will serve: Residence____ Commercial_ Other V Number ofii4tlag units: Number of bedrooms } + f Character of soil to a depth of 3 feet: _ Water table depth — ` r ' SEPTIC TANK I -fit”/ 2Type/Mfg 6011 -rr1T5L � " Capacity 20a No. Compartments } PKG. TREATMENT PLT. ❑ '.{ Method of Disposal Distance to nearest: Well �� fi Foundation 14 4 ~'Property Line LEACHING LINE LL1" No. & Length of lines t r Total length/size 0"" FILTER BED El 'Distance to nearest: Well 6 �' _ Foundation - r-75 ,Property Line • x r , SEEPAGE PITS > W" Depth Size J 3` Number SUMPS r 0 Distance to nearest: Well 'Foundation /©n Property Line 7 i DISPOSAL PONDS ❑ ' hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an I rules and regulations of the San Joaquin Local Health District. A �� 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'rdf 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 X. �},�h� '_ 2-,,'AD, Title: . 91-t L Date: •7 S' + i FOR DEPARTMENT USE ONLY 's 3gq Application Accepted by Date Area Pit or Grout Inspection b Date _Fin In pe tion by r s Date A) ef f Additional Comments: !hZitig, t7 i ❑ Stk 466-6781 9❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH �; —y-RECEIVED BY- :% `D'ATE' PERMIT NO. + EH 13,24(REV.I/n 51 W7c 1r1�5 } SPD kk EH 14.26 % 4