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1 APPLICATION FOR PERMIT _ a, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE„ STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ' Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is r 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 f j Job Address 1'S g&f T) 4)2) City e, Lot Size J 00 x I 00— PM Owner's Name l- Cr pJr-11 V C3jarIe.l�___ Address Phone f 7 Contractor Address 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public R Other 171 Delta Depth of Grout Seat Type of Grout I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done 0 Type of Pump H.P. State Work Done c Well Destruction ❑ Well Diameter Sealing Materia! Itop 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION i I DESTRU 1 (No septic system permitted if public sewer is 'lable within 200 feet.) Installation will serve: Residence)L Commercial T Other ,/Number of,tiving units: Number of bedrooms 3 Character of soil to a depth of 3 feet: _45- et fel 0 W ;S ~ Water table depth SEPTIC TANK Type/Mfg C 0 0 C._Re` Capacity j QQ No. Compartments i PK G. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well A roundatGin Property Line s i 4 EACHING LINE ❑ No. & Length of lines Total length/size { j FILTER BED ❑ Distance to nearest: Well Foundation Property Line 3 t F 4 SEEPAGE PITS i I Depth Size Number j SUMPS ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑' •t ..-.-- f – .-».—�� r 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 r rules and regulations of the San Joaquin Local Health District. I 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 t femploy 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 taws of.Califomia." k The applicant ust call for r utred inspections. Complete drawing on reverse side. Signed X Title: Date: i © FOR DEPARTMENT USE ONLY �r Application Accepted by Date�j�+� Area Pit or.Grout Inspection Date -,.Final Inspection by/: Date Additional Comments: S �— ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'N0. INFO + EH 13-24 MFV.1/K 51 ` EH t4-M *CS CD - �6 1 / $"�7