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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601'E. HAZE T ON AVE., STOCKTON, CA i 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 1 Local Health District. ��,��,, ' J (Job Address C 4 LO �'L�[ � - City /8!� Lot Size ~ X 06) /PM )(Owner's Name/ 4-C &14e&` Address�.2�v,/-y ','e-I--ACl_ '7_ Phone KContracto f Addres " � �T Lic e No.51f 3 7 Phon�3F TYPE OF WELL/PUMP: NEW WELL ❑ ELL REPLACEM T ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM PAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LI S DISPOSAL FLD. _PROP. LINE FOUNDATION AGRICULTU LL ''OTHER-WELL ^'� PITS/SUMPS " ---"'�INTENDED-USE—TYPE-OF-WELL PROBLEM"AiREA`�" STRUCTION-SPECIFICATIONS O Industrial.- __ ❑.Open.Bottom = .❑ Manteca-. Dia.. -Weld Excavation --- - - y Dia. of Weil Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o Casing " .r Specifications f Public fl Other f 1 Delta Depth of rout Seal Type of Grout _ I i Irrigation _..Approx. Depth I 1 Easter Surface Se Installed by _ 1 Repair Work Done ❑ Type of Pump H.P. State Work Done .._ Well Destruction ❑ Well Diameter Sealing Material It 50'1 Depth Filler Material i8elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION i I (No septic system permitted if public'sewer is ' available within 200 feet.) Installation will serve: Re idence Commercial cher Number of living units: [ Number o1 bedrooms_� C � Character of soil to a depth of 3 feet: LOAM -.%�, I � __ _ Water table depth 3 r D 61 SEPTIC TANK J$( Type/Mfg av+it�� , ` Capacity �� No..Compartments I _ PKG. TREATMENT PLT. ❑ / Method of Dispopl Distance to nearest: Well �_®O Foundation iD Property Line `- LEACHING LINE '4 No. & Length of lines �? =- Total leng[h/size r FILTER BED ❑ Distance to nearest: Well .- 1Sb Foundation— 10- - -Property.Line f / i SEEPAGE PITS K Depth — ,. Size f!9 Nu bar SUMPS- Cl Distance to nearest:~ 'Well" �D(d4 Foundation Property Line �_v _- POSAL PONDS ❑ 4 I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Diltrict. Home owner or licensed agent's signature certifies the following: '1 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 i 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." L t s The applican must call for I quired inspec 'ons. plate drawing on reverse side. f Signed X Title:Z2-,ei-,-1 C.4 ,/ - r^ Date: /~ 9 R DEPARTMENT_USE ONLY Application Accepted by __ �A�/ti� _ 1� �,�„ _ Date �� ~ r I Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 t71 Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 `INFO� AMOUNT-DU E ^` '—AMOONT REMITTED CASHT RECEIVED BY b DATE PERMIT'NO. +.EH 13-24 If1Ev. EH 14_28 7 /0"' k