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i APPLICATION FOR PERMIT.- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA K Telephone (209) 466-6781 PERMIT EXPIRES I 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. �,617 AJC �/� Lam✓ L �� City Lot Size c---- PM Job Address ! i Owner's Name Inn Address R61 ��-G ��i_ Phone Contractor A o, Address_a, �� /� License No.� Phone � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ '—DESTRUCTION ❑ 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 ❑ DomesticlPrivate ❑ Gra al Pack " ❑ Tracy,, Type of Casing Specifications I'] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ {w� I 1 Irrigation .T-Approx. Depth t ] Eastern Surface Seal Installed by - v 1 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material (top 50') 1 i - Depih- - -„ .►Filler Material (Below 50'1 TYPE OF SEPTIC WORK:'-NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is G ;- available within 200 feet.) Installation will serve: Residence Z Commercial_�Other , Number of living units: -I— Number of bedrooms ""- i Character of-sail to a depth of 3 fear. ��O Water table depth SEPTIC TANK ❑ Type/Mfg Capacity' Ld ---_ No. Compartments PKG. TREATMENT PLT'. ❑ Method of Disposal AFT F4A t Distance to nearest: WellProperty Line rFoundation 0�"`* LEACHING LINE No. & Length of lines Total-length/size y�7r A Foundation F Property Line •� FILTER BED' ❑ Distance to nearest: Well _.., `�? z� �.. SEEPAGE PITS Depth F Side Number SUMPS 0 Distance to nearest: Wellx�_��aundation! '� Property Line DISPOSAL PONDS % .r-J:-i- I hereby certify that I have prepared this application and"tKat the work will be done iWaccordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ` w 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 subject4o 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." '1Y._ The applicant must call or all uire inspections. Complete drawing on reverse side. Signed X Title: zoee_ «� Date: /J" FOR DEPARTMENT USE ONLY _ Application.Accepted by DateA�&:Airea �t, ),r Pit of Grout Inspection by Date Final inspection byd f < Additional Comments: f M ❑ Stk 466-6781f ' ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6386 Applicant Return alj copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Y �Z FEE AMOUNT DUE tea, AMOUNT REN{ITTED} CASH' RECEIVED BY BATE PERMIT'N6. a:EH 13.24 IREY..I h 5Y <,�-. —.��+: — D. (p- �^` I " f � `