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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT + 1601 E. HAZEL T ON AVE., STOCKTON, CA rr 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. / Job Address 0742,96a D Isk-Amael City Lot Size PM Owner's Name�/�/ / 's`�' �" v�� (K7'b �• r�4J/ one t)LVAr PCS ,861 3 Z3 CLf/1? KS . �3�/ 7.39 3335 Contractor E. K. L3R Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ LL AC E ❑ LJiESTRUCTION ❑ PUMP INSTALLATION ❑ �` " $ R**❑ 1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL P'kD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �tl ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing p0 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications N !'1 Public Cl 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 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence✓ Commercial_ Other ✓ la DE 0- DEPE./YDENT PARENT Number of living units: __P_ Number of bedrooms 6 'in ✓ Character of soil to a depth of 3 feet: LOAM Water table depth SEPTIC TANK I/Type/Mfg MATREFE Capacity Al Da !sW_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Z�z Foundation Z�Q Property Line Z75 a LEACHING LINE EK'No. & Length of lines 3 `��7 Total length/size � FILTER BED L?' Distance to nearest: Well 26d• Foundation ZDd' Property Line 275' SEEPAGE PITS IK Depth 25' Size 3L Number µ � SUMPS C Distance to nearest: Well .331• Foundation ! I Property Line Z75 DISPOSAL PONDS ❑ 1 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 Califor The applicant u all for all require i spe io . Complete rawing on r�ey�/QSa side. Signe Tit �j C.X /!� Date: `-"'r0/ le: - _ - _ FOR DEPARTMENT USE ONLY Application Accepted by Date � / Area ` _ i r Pr� or Grout Inspection by Date �oZ /- Final Inspection by � Date Additional Comments: 1' ' f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑'Manteca 823-7104/ ❑ Tracy 835-6385 /v T/D Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, .1; k., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. L , INFO I CASH EH + EH 114-ZB 3-24(REV.tins) Illi I rG�.4�� a9l -5 1fy--)A, ID / /