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lyc . -�►�" APPLICATION FOR PERMIT 9 SAN JOAQUIN LOCAL HEALTH DISTRICT �` ✓ 5 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.A Job Address / /� � "a City Lot Size J.6/94— PM Owner's Name 4 C6/ 44d AA) &alAdclr ss Phone Contractor ave— Address License %r, _7� Phone1t?49d TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 F1 Public 1-1 Other ❑ 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. State Work,Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I*-REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is A,10_ _ available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: J_ Number ofAPT oms Character of soil to a depth of 3 feet: Water table depth i(4 SEPTIC TANK (Type/Mfg Capacity 6V No. Compartments 2-- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 6© 1 Foundation d a Property Line LEACHING LINE 4-"'No. & Length of lines -03 7 Total length/size FILTER BED ❑ Distance to nearest: Well Q f Foundation Property Line fw SEEPAGE PITS I44 Depth JA t Size _ Number SUMPS 1_1 Distance to nearest: Well f Foundation Property Line 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 st call for all requir ins ctions. Complete drawing on reverse side. c GcJ�c�C �_A` dQf' Signed X�2�'��w Title: � � Date: . / FOR DEPARTMENT USE ONLY Application Accepted by Date r Area _ Pit or Grout Inspection by Datef r Final Inspection by 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 95201FEE t INFO AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DATE PER MIT•NO. +.EH 13-24(REV.1/8 5) 1^ !� EH 14-26 n p V ��I_l