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APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Is. Local Health District. r Job Address ---��''� S• ESCAL0N19r.� L OTA a City Lot Size /40 QG. PM Owner's Name 6-sTF-e--TgmXley _ Address 100-0 DA V1 S Phone L/V1A-A 5 E Contractor ._12&1 Ist a Address License No. Phone TYPE OF WELL/PUMP: N NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTE REPAIR ❑ 1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER (NES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICU TUBE ELL OTHER WELL PITS/SUMPS s INTENDED USE TYPE OF.WELL- PROBLEM AREA NSTRUCTION SPECIFlCA710NS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe of Casing Specifications Fl 1 Public ❑ Other ❑ Delta D th of Grout Seal Type of Grout I I Irrigation --Approx. Depth I 1 Eastern Su a Seal Installed by _ Repair Work Done ❑ Type of Pump P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth y Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence-Z Commercial_ Other - €� Number of living units: Number of bedrooms_.-3 f Character of soil to a depth of 3 feet: Water table depth APADO SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I— 1 PKG. TREATMENT PLT. ❑ Method of Disposal L Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines ��, Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line - r SEEPAGE PITS I 1 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line I 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 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 re uired inspections. Complete drawing on reverse side. ''AA Signed X6 `_ _ Title: Date: cV —Z4—&� {{// ,-�� FO DEPARTMENT USE ONLY R Application Accepted by ' ZZ Date Area Pit or Grout Inspection by Date Final Inspection by P41W Date � 13) �0 u ID . Additional Comments: 4 � l)f 3_�p t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca 823-7104 ❑ Tracy 835-6385 A Is Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Z, FEE s INFO OUNT DUE AMOUNT REMITTED C 8�1 RECEIVED BY DATE PERMIT NO. 3-24 i EH 114-26(REV. 7o.i n 5] 0� qD-ID A3 1 y/V �/ V71- k3 u