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f 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) .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. ,,� Job Address ? ,.t�L&&12 fes/ City ,ate f Lot Size PM Owner's Name 40` °�` - Address7 7.Z_ 7/,�' 4. [aro Phone 7�r' Contraclar/��'-- Address `� ��/�� >�A/�/� License No. "r�/!�/ Phone �Zf 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f"1 Public ❑ Other ❑ Delta Depth of Grout Seat Type of Grout I I Irrigation --Approx. Depth t I 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 501 r r� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION-1-l- DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other .M4"%X1 Number of living units: Number oA bedrooms �' F Character of soil to a depth of 3 feet: r- _-_ Water table depth 60 SEPTIC TANK CT�_Type/Mfg• eAA.) t4Z— Capacity /&CU No. Compartments Z PKG. TREATMENT PLT, ❑ u�. Method of Disposal Distance to nearest: Well//dp Foundation /, 0 s ,Property Line LEACHING LINE IrYNo. & Length of lines . Notal lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation P S t Property Line OD l �) SEEPAGE PITS Ibro"Depth r�� f _Size =4r Number SUMPS ❑ Distance to nearest: Well ,I (Foundation 60t Property Line 's DISPOSAL PONOS ❑ f 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, aT* 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'Calif&66'." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." t The applicant must call for II r9oluired inspections. Complete drawing on reverse side. Signed X Title: /—V /r Date: R DEPARTMENT USE ONLY ` Application Accepted by Date ( ?0 b w7 Area 2— Grout Inspection by Da 'k 7Final Inspection byfiDate it 6 Additional Comments: ❑ Stk '466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63145 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a eX FEE AMOUNT DUE~ AMOUNT REMITTED ICK RECEIVED BY DATE PERMIT'NO. INFO n EM 13-24 ��j / ? JJ} * EH 14-�IREV.iiHsl 7l�r V�/ G