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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. 1 Job Address 3�lP �evDSO�l �p City .4Cfir7YJP4 Lot Sixe ��.YiL1 99 P 6-16— /k F e47& Owner's Name /!ate Tom'.+ Address Phone ContractorFL 8 1�E. Weep Address 7 .ed, 4 D_1 LrB x'0_2- ,�WX License No. �dy 1i7� -Phone .TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION+❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _c DISPOSAL FLD. +r PROP. LINE , F. FOUNDATION AGRICULTURE WELL OTHER.WELL PITS/SUMPS r INTENDED USE - TYPE OF WELL `rj` PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottotn ❑ Manteca Dia. of Well Excavation ' ` Dia. of Well Casing 441 �.,Domestic/Private 171 Gravel Pack ❑'TracyType of Casing Specifications i 1`1 Publin 17 Other �, 11 Delta Depth of Grout Seal t Type of Grout I,I Irrigation A .. 1 g' _.. Approx. Dej�th l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump _ M,P. r State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filll r Material-(Below_50'4 ' TYPE OF SEPTIC WORK: NEW INSTALLATIONA 1 REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is I. ,,. available within 200 feet.) t Installation will serve: Residence . Commercial t_ Other Number of living units: � Number of bedroll . 3 < . Character.of soil to a dof 3 feet: L- _ ion/ _ r F "^'- Water tablg+depih ept f SEPTIC TANK Type/Mfg tn � -�9�L ' y - Capacity`^! 7-0 z7 No. Compartments r PKG. TREATY NT`PL '�`'"`-� .� Method of Disposal s Distance-to.nearest: Well /OBftoundation f roperty Line LEACHING LINE No. & Length of lines FILTER BED ❑ Distance to nearest: Well�_ Foundation 0 Property Line SEEPAGE PITS I' Depth 7- Size. 3,3 4' -Number__ SUMPS Ll Distance to nearest: Well Fou'dation /d'0 41 Property`7'aJT7Or- k 1 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-" Cbntractor'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-requited inspections. Complete drawing on.reverse side.? o� Signed Xevi, Title: bate: 7�1�'g� FOR DEPARTMENT'USE ONLY Y ry- J ; Application Accepted byDate 7`�lO,�fl_0 ' �.� Area r �� Oddnional or Grout Inspection by 'Date Final Inspection by DateComments: ; r ❑ 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 95201 FEE _ r ~ § INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED By DATE PERMIT'rNO. + EH 3-24 EH 14-2tS/REV.I/n 5! D, vj