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i ~ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telepho6e (209) 466-6781 PERMIT EXPIRES 1 YEAR 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. Cit Lot Size 04 PM -94 , Job Address _ Owner's Name �/ .L ��- -�— Address _ � - Phone ' Contractor_Z&Y� Address License No._J672,1'_ Phone��r - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT EI 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 ❑ Industrial ❑ Open Bottom -1Manteca Dia- of Well Excavation Dia. of Well Casing k Type of Casing Specificationst ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yP 9 r-1 Public FIOther n Delta Depth of Grout Seal Type of Grout - V� I 1 irrigation _._Approx. Depth I I Eastern Surface Seal Installed by I' L� I ' tate Work Done I " "� Repair Work Done ❑ Type of Pump H.P.HP Well Destruction ❑ Well Diameter Sealing Material (top So Depth - Filler Material IBelow 50: 11 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is _ available within 200 feet.) t installation will serve: Residence Commercial_ Other 1 Number ofliving units: Number of bedrooms C" . ; \ Water table depth Character of soil to a depth of 3 feet: .+3 N\ SEPTIC TANK El Type/Mfg { Capacity "�! No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 3 '^� • Distance to nearest: Well � ` . Foundation Property Line kA I � l isr LEACHING LINE �--No. & Length of lines l / � _7otaih'length/size a I FILTER BED! ❑ Distance to nearest: Well��_-__ Foundation L. f Property Line !.— t 1 SEEPAGE PITS I�Depth Sae ' Number �. i �r l f SUMPS L� Distance to nearest: Well - 'jF�o�ndation Property Line - 4 ISPOSAIL PrONDS ❑ � rk{ I herebylce'r4y that I have prepared this application and that the wowill be done-,in accordance with San Joaquin county ordinances, state laws, and=�y rules and regulations of the San Joaquin Local Haiti District Home ownerlor 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 becomefsubject to workman's..compensatioh-laws-of Galifornia." Contractors hiring or sub?contracting signature certifies the following: "I certify that in the performance afi the work for which this permit is issued, I shall employ persons subject to workman's compensa- f tion laws of California." � s I I The applicant must call f r all eq irod�inspections. Complete drawing on verse side Signed X tTitle: Dater E FOR DEPARTMENT USE ONLY Application 1ccepted by Date w"_ 4C Area it r Grout Inspection by T ate Final Inspection by Date Additional Comments: ❑ Silk 466-6781-----B-L-adi:369=36224.—❑-Manteca°X823=7104 E� Tr cy-835--6m6--w Applicant - Return all copies to: Environmental Health Permit/,tServices 1fiQ1 E. Hazelton Ave., P.O. Box 2009, S1k., CA 95201 AMOUNT DUE AMOUNT REMITTED 4 CK RECEIVED BY DATE PERMIT N0. FEE CASH INFO +.EH 13-24{REV.i i m 5; EH 14.29