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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.. HAZEL T ON AVE., STOCKTON, CA k Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ( � 3 (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District 7572- Job /2Job Address "'�' FAz,e-eA 1W_D Aikk city S;,� Lot size. 2,g�e `AqG PIM Owner's Name -YV;P_ -S. V14,eS Address 5Ai97E Phone ®6d� Contractor F6:O p F_. Lzl ,� AddressAl, "L/�e A� _License No. �d Y�� Phone - 197 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1-1 ! 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 1 ❑ Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications s a"❑-Public it 1' ❑ Othiar r f ElDelta Depth of Grout Seal Type of Grout ❑,Ir"rigation _�lpprox.,Depth ❑ Eastern Surface Seal Installed by Rep air.Work Done ❑ eyp e'-of Pump ,flH.P. State Work Done i Well Destruction ❑ Well'Diameter Sealing Material(top 501 " Depth Fills rWaterial {Below 50') ' j TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 11DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation vuill serve: .'Resid'enceCommercial_ Other F 7��,,// C , . Number of living units: Number of bedrooms Character of soil to a depth f 3 feet: Water table depth �• f r SEPTIC TANK fie # Type/Mfg - Capacity L COQ No. Compartments y PKG. TREATMENT'PLT. ❑; Method of Disposal '�! � 6 pis#ance_ta.nearest: v„�Well Foundation Property Line 1 LEACHING,LINE T No. & Length of lines 2- SS Total length/size67 J X Z FILTER BED r❑,YDisfance to nearest: Well Foundation c-7& Property Line�r SEEPAGE PITSf J _ Depth aS Size 3 -- Number 02- SUMPS ❑ Distance to nearest: Well_/450— Foundation /4&O A Property Line I i DISPOSAL PONDS ❑, > -.:. _p r I hereby certify-that I-have1prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I rules and regulations of ttielSan 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." J The applicant must call for all squired ins ions. Complete drawing on reverse side. yf.Signed Title: -- _.-...- _. . Dated t L/ " S FOR DEPART T USE ONLY 4 ,Application Accepted by Data �V Area Pit or Grout Inspection by ? Date '' Final Inspection by M` Date - k Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 �❑ Tracy SW 385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO +EH 13-241REV.1/65] 7O EH 14-28 i 4 ,�