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APPLICATION FOR PERMIT ' j SAN JOAQUIN LOCAL HEALTH DISTRICT :I 1601 E. HAZETON AVE., STOCKTON, CA j� Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED I� (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-wkh 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. I l ie&re� Lot Size �l0 /9GY�y PM ' Job Address , O dIV..5 OM f�ve City p II G e�. Nes SG,AT e7 Address 6�Q° I�r v r S I off 1 d' Phone A 37 Owner's Name � - Contractor /�NTI�ti SO!! Address 64�Z 9Ft e- v�� pLicense No. "Y TYPE OF WELL/PUMP: 7NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE !a FOhUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l ❑ Industrial - [IOpen Bottom 1-1Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing S Specifications I'1 Public Cl Other ❑ Delta Depth of Grout Seal Type;of Grout -. Q I i Irrigation 'l -Approx. Depth l 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 ! Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION flEPAIR/ADDITiO N l 1 DESTRUCTION I 1 (No septic system permitted if public sewer is iI available within 200 feet.) Installation will serve: Residence— Commercial Other ms b-, �" vAl Number of living units: � Number of bedrooms Character of soil to a depths of 3 feet: Water table depth r ' SEPTIC TANK Jf fType/Mfg Pre C7,glr la-f L Capacity 14,947No. Compartments �+ Method of Disposal PKG. TREATMENT PLT. ❑ t Distance to nearest; Well Foundation Property Line LEACHING LINE V7 No. & Length of lines Total-length/size— FILTER BED ❑ Distance to nearest: Well Foundation Property Line n SEEPAGE PITS I 1 j� Depth Size Number SUMPS ❑ II Distance to nearest: Well Foundation Property Line- - DISPOSAL PONDS ❑ !� 1 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 rules and regulations of the San Joaquin Local Health District: w 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." �1 ' 1, r The applicant mu call far all required inspections Complete drawing on reverse side. �.g I i Date: q"�G►' 4b Signed X d� Title: -o � F. SPAR ENT USE ONLY Application Accepted by Date'"` U a � Pit or Grout Inspection by Date Final Inspection by Dat��+'9 Additional Comments:It, I" 1� Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6385 i '� "'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 CASH RECEIVED BY �., DATE PERMIT'NO. INFO _ 11 O a E}1 13.24(REV.i R 51 I ,b� 'IA 1 :To-) EH 14-26 III �'