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t APPLICATION FOR PERMIT 6 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466 6781 NO PERMIT EXPIRES 1'YEAR FROM DATE ISSUED j (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 Sari Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin ai Health District. I Joh Address/,8W/ 9&Z6 K_ /l ___ City Lot Size PM Owner's Name Address Mol //��(e 1—d• Phone z� — L77 Contractor Address 4 License No. Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ R•, w DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICUL ELL OTHER WELL PITS/SUMPS F INTENDED USE TYPE OF WELL PR AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I Cl Domestic I Private ❑ Grav ck 17 Tracy Type of Casing Specifications F1 Public ther Ci Delta Depth of Grout Seal Type of Grout x I Irrigation __-Approx. Depth I I Eastern Surface Seal Installed by t _ Repair one ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 501 f Depth Filler Material (Below 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION I1 M-PAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is vailable within 200 feet / t f Installation will serve: Residence_ Commercial 9 Other - r I' Number of living units: Number of bedrooms t� Character of soil to a depth of 3 feet: 4 Water table depth k SEPTIC TANK` ❑ Type/Mfg Capac'ttity � No. Compartments PKG. TREATMENT PLT. ❑ t Y Method of Disposal k i Distance to nearest:.-,,:- We11' Foundation` Propdrty-Line t I , j LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation— -Property Line SEEPAGE PITS ('l Depth Size " Number- SUMPS umberSUMPS 0 Distance to nearest: Well _ Foundation Property Line + i DISPOSAL PONDS ❑ t { 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 DiMrict. j 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 work an's compensa- tion laws of California." The applicant mjo9t cAI for all required inspections. Complete drawing on reverie side. Signed X Title: -._-_ Date: f F EPARTMENT USE ONLY tf- Application Accepted by `may Date rArea Pit or Grout Inspection by' '' a Da[a 'Final Inspe by Data Additional Comments: U 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 INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT N/O. r.EH 13-21 E 11-28 J C (/ Z. r�/s Z H __ _ 7