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r I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 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 off the San Joaquin Local Health District. Job Address CityUd/�� Lot Size A`4' - PM Owner's Name ' L115"h1VJAS'LA1_eJ_ Address Phone iContractor's Name ' ! License No. Phone }TYPE OF WELL/PUMP: , NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ 10 SYSTEM REPAIR 11 OTHER C3.DISTANCE TO NEAREST: SEPTIC TANK y 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 A ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation __�_4pprox. Depth ❑ Eastern Surface Seal Installed by1 Repair Work Done . ❑ Type of Pump H.P. State Work Done t Mall Destruction ❑ Well Diameter Sealing Material (top 50'! 1 Depth Filler Material (Below'.50.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADD IjTION W, DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 4 Installation will serve: Residence Commercial_ Other Number of living units:T Number of bedrooms lle!:� i Character of soil to a depth'of 3 feet: '�� Water table depth SEPTIC TANK Type/Mfg ,Capacity LIQ No. Compartments PKG, TREATMENT PLT. ❑ s Method of Disposal Distance to nearest: Well /2d2 Foundation _'Property Line 7 ?' V ! a., LEACHING LINE ' No. & Length of lines �-" �� Totalflengih/size z r Y (FILTER BED ❑ 'Distance to nearest: Well_�l Foundation NIC2 Propertyy"Line i O / SEEPAGE PITS ❑ ",Depth Size fir'.t, SUMPS ❑ [Distance to nearest: Well Foundation; °'Property Line DISPOSAL PONOS ❑ 1 1 hereby certify that I have prepared this application and that the work will be done iri accordance with SaniJoaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local-Health-district:-^- ► I i 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 empioy persons subject to workman's compensa- tion laws of California." L The applicant must call for all required inspections. Complete drawing on reverse side. } { Signed X r — Title: � �,: t ,l� � #�� Date: 77-1 FOR DEPARTMENT USE ONLY 1117 Application Accepted by Date Area r/ � n 7-I( Pit or Grout Inspection by ' Date Final Inspection by_!�i�Y3 ..41A. ate I Additional Comments: r 1 l❑ Stk 466-6781 El Lodi 369-3621 -❑~Manteca- 823-710,ire --©Tracy.-835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'`NO. INFO CASH +EH 33-24(REV.101631'may •J:. 1"F' ~ - • ,. EH 1426 �1r }