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i i APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.MAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES1 YEAR FROM DATE ISSUED " it (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. Tl is'application is I made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin i Local Health District. 1 ' Job`Address �:e X44 CczLJaTr D _- City LAG Lot Size e ill L PM �L «. � „ Owner's Name V, Address E Phone F h Contractor Address Z00\C Ali "WeLicense No.AtYd;- a Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR .0 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's Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter -Sealing Material (top-50'1 - Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 0 available within 200 feet.) a Installation rwill serve: Residence— Commercial Other AG�i Number of living units: •— Number of bedrooms r f Character of soil to a depth of 3 feet: 5-d2 eD V L-”m - GL!4X __ Water table depth SEPTIC TANK CR/Type/Mfg _.-e 0- Capacity 12-49 0 No. Compartments "2— � PKG. TREATMENT PLT. ❑ '" `'r Method of Disposal G Distance to nearest: Well /1.0 Foundation�� _ Property Line LEACHING LINE No.-&-Length of lines �6i2 Total length/size "XZ FILTER BED ❑ Distance to nearest: Well /1D Foundation Foundation 2D ' Property Line d4 SEEPAGE PITSIR/Depth _Size 3 ' Number SUMPS ❑ Distance to nearest: Well Foundation l0eq Property Line -DISPOSAL PONDS ❑ f A 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; "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 California." , - The applicant must call for all-required inspections. Complete drawing' on reverse side. Signed X_ Tate Lsr Date: lD-Ll-8 - � FOR DEPARTMENT USE ONLY Application Accepted by' Date CMZ Area 1 it or Grout Inspection by Date�°2" -Final Inspection by Date/ 6. Additional Comments: ❑ Stk 466-6781 IPi Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6395 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton AGe' .P;O. Box 2009, Stk., CA 95201FEE �N INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY. DATE' PERMIT"NO. + EH 13-24(REV. 4'5- EH 14213 ' II