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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k (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 Local Health District. Q f Df�dds d'+ City '�SCg94W Lot Size PM Job Address q Owners Name 130->-&o9 dam; r Address jD ceOds Q d Phone Cont,16or tyT 6 tF& 't; O& Address V ae`if Aw"', License No. Phone TYPEPF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I 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 ElIndustrial (_1Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing { ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [-I Public F_ Other ❑ Delta Depth of Grout Seal Type of Grout k( I I Irrigation _Approx. Depth l I Eastern Surface Seal installed by - Repair Work Done ❑ Type.of Pump H.P. State Work done— \ Well Destruction ❑ Well Diameter - 1Sealing Material (top-50E k Di�ptK"' �'�` ""`-�1 ""` Filler Material.IBalow_50'I t — TYPE OF SEPTIC WORK:r NEW INSTALLATION 4A REPAIR/ADDITION I I DESTRUCTION I I (Nosepiic system permitted if public sewer is available within 200 feet.) I Installation will serve: "Residence ! Commercial�_ Other Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 'fes 1 SEPTIC TANK Type/Mfg A&e cg, r`' p+i �.. Capacity i Q No. Compartments x PKG. TREATMENT PLT. _ _ __ -__Method of Disposal i Distance to nearest: Well Foundation" Foundation 7r� Property Line ��0+ LEACHING LINE No. & Length of lines �� Total length/size FILTER BED ❑ Distance to nearest: Well 100 ` Foundation Property Line �0 SEEPAGE PITS I>1 Depth Size Yr K4 IP — Number SUMPS In Distance to nearest: Well 1000 Foundation SCO Property Line pe DISPOSAL PONDS O 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. Home owner or licensed.agent's signature certifies the following: '9 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.' The applicant mus cah4or_all required inspections. Complete drawing on rave se side. Signed X Title: Date: R DEP TMENT ONLY Application Accepted by Date Gp "57 Aida I Pit or Grout Inspection by Date y --Final Inspection b Date Additional Comments: *' ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box.2609, Stk., CA 95201 9 1 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT'NO. w� INFO CASH. t ♦-EH 13-24 IREV.I/H 5) ' EH 14-26