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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (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. f Job Address _45,_M(a - &tylew City_ sTrxk .sxotSize PM Owner's Name />> Address �igrr,,� Phone ?-?,/-411,91 Contractor ri-SotJ Addsess9 w License No. PhoneG TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cn 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (°l Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth i I Eastern Surface Seal Installed by. Repair Work Done ❑ Type of Pump H.P. 0. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION X DESTRUCTION'191 INo septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence A Commercial— Other Number of living units: Number of bedrooms q Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 34 Type/Mfg �if' L. Capacity 164a _ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation S Property Line 10 LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Dt�� Foundation ��' Property Line SEEPAGE PITS Depth a4_ Size 3e. Number SUMPS ❑ Distance to nearest: Well Foundation A0 Property Line ly DISPOSAL PONDS ❑ - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin Local Health Di1trict. 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." Contractors 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." The applicant must call for all r q ired inspections. Complete drawing on�re'vversse side. Signed X r Title: LA-- Date: -7-/,D ' FOR DEPARTMENT USE ONLY Application Accepted by Date_ 7/0,/o Area o Pit or Grout Inspection by Data .: Final Inspection by Date ` Additional Comments: ❑ Stk 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 FEE INFO AMOUNT DUE AMOUNT REMEI7ED CASH RECEIVED BY DATE PERMI7'NO. +.EH 13-24 MEV. n 5) 7�0 EH 14-26 5 P