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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hepeby 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 3 3 3 S� C, Uci c%�S 1�0� City 09C;,9 t- i Lot Size .4&9 C4 PM C Owner's Name WoMK /30�-G A Address id-Ve_ Phone Contractor .!C +�M�oAr oAv . Address 400.1 Q�ve uny .4ve License No. !ng -,f Phone S'7$�y��'j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 4 DI57NC A E TO NEAREST: SEPTIC TANk SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Y4TENDED USE TYPE OF WELL PROBLEM.AREA CONSTRUCTION SPECIFICATIONS–m- 0 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy s Type of Casing Specifications „i7 Public ❑ Other ❑ Delta ` Depth of:Grout"Seal 'Type of Grout _ "I i Irrigation w ___ .Approx. Depth l I Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. .State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth _ Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public-sewer is available within 200 feet.) I, Installation will serve: 'Residence /_ Commercial_ Other d Number of living units: I Number of"b�e�drooms -� Character of soil to a depth of 3 feet: 3 l.0 xm.4/r4 Water table depth SG� SEPTIC TANK In Type/Mfg _46 eo,T Capacity J Aay No. Compartments PKG. TREATMENT PLT. ❑ ° - Method of Disposal . I f Distance to nearest: Well s'�d' Foundation f Property.Line 4, LEACHING LINE lel No. & Length of lines LS' s Total lengililsize 1 3v' 4+ FILTER BED ❑ Distance to nearest: Well 5-00 • Foundation So Property Line SEEPAGE PITS I [ Depth g� Size` t, w,f,k. nNumtier SUMPS Distance to nearest: Well soQ Foundation JVD• z �f � Property Line /at 117;- DISPOSAL +•DISPOSAL PONDS ❑ L hereby certify.that L 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. t 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 shalt not employ any person in such manner as to become subject to workman's compensation laws of California.'-Contractors 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." I The applicarit must call for all required inspections. Complete drawing"on reverse side. ,,c p Signed X Title: ��1/. dGl1�t Date: //? A8n I FOR DEPARTMENT USE ONLY Application Accepted by Date - Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ' O Silk 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 3 FEE INFO AMOUNT DUE AMOUNT �REMITTED CK H RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.t/K 5) EH 14-26 G LLLfff