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i �- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (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. y Job Address r r�Cl City 95 �� Lot Size /�QCcCi'et PM �f Owner's Name t Ad dress � tl'Gyt� Lr'eek �� ► Phone !-!� �-678 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 W ❑ Industrial ❑ Open Bottom - ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t ❑ Domestic/Private ❑ Graver Pack ❑ Tracy Type of Casing Specifications F1 Public 1_1 Other ❑ Delta Depth of Grout Seal Type of Grout _. I I Irrigation ' __..Approx. Depth l I Eastern Surface Seal Installed by _ 'h Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 r" Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION .I REPAIRIADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is t. lnstallatiori available within 200 feeLl}will serve: Residence� Commercial_ Other � a-s3 �``� t �� Number of"living units: ! Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK` Type/Mfg Coh C-y�+� Capacit 4 G 570 No. Compartments PKG. TREATMENT PLT. ❑ ( f Method of Disposal y „r k Distance to nearest: Well ;LIDO f=oundation /00 Property Line LEACHING LINE No. & Length of lines _ _ 8, Total length/size x „r r , .FILTER.BED ❑ Distance to nearest: Well,_ Foundation Property Line t - SEEPAGE PITS K Depth 5 Size 3V r, 2-5 _ Number 10 SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I ❑ I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and Yegulations of the San Joaquin Local Health District. - 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 Cali rnia." The applicant u tali for all required in coons. Complete drawing on reverse side. J I7 Signed X _ Title: Date: r fAyl p T F. DEPARTMENT USE ONLY ik Application Accepted by AA ' Date Area Pit or Grout Inspection by Date Final Inspection by e " � at x _ ;' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 1335-6365 " . .... Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20FEE 09, INFO AMOUNT DUE AMOUNT REMITTEO KSH 1RRECEIVED BY DATE PERM �-I fT-NO. +..EH 13-21 EV.i i rt 5l 0 `�` J / EH 14-28 i -