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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA 7. Telephone (209) 466-6781.- PERMIT 56-6781•- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) FApplication 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. �1 b Job Address 39L 7`' C P(eSS f"r f� City r d Lot Size PM Owner's Name C-Qf/1 ROAk"I'10 Address sQwte, Phone Contractor .�r _... u1(�,� Address f B f License N0.�.jyhona � i ;{~ -TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ � DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE t; . FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ` Type of Casing Specifications Fl Public D Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation ' __-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of PumpH.P- State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth -0° Fiber Material (Below 1 TYPE OF SEPTIC.WORK: NEW INSTALLATION 11 REPAIRIADDITIONDESTRUCTION I I (No septic system permitted if public sewer is '" available within 200 feet.) ,J Installation-will serve: Residence _ Commercial_Other Number of living units: _N,umberr of bedrooms g Y Character of soil to a depfh''of 3 feet: ,5& ' 1 I « Water table depth SEPTIC TANK _ ❑ Type/Mfg V Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method"of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines =� X 3a Y a 'Ut.Mrigth/sizeff V FILTER BED Distance to nearest: Well"'"�""`"'kms Foundati n Property Line�-.1'0-____.-_--_ SEEPAGE PITS I l Depth Size Number ] ; SUMPS iLl Distance to nearest: Well Foundation Property Line (T]� DISPOSAL PONDS ❑ 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. 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.•- - �-. - - - -- 7 - . The applicant must call for all requir d i spections. Complete drawing on reverse side. Signed X Title: o11_& Date: 4/ R A� FTIIVIENT USE ONLY Application Accepted by ~/ Date Area Pit or Grout Inspection by Date Final Inspection by WAf, Date Jr Additional Comments: ❑ Stk 466-6781 -D Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O.' Box 2009, Stk., CA 95201 ~ w INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24IREV.1/H5� 9 EH 14-29 i