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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT < I, 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. -i p i /� /� Job Address 1 912 &1, Ay o rg A va• City L flko Lot Size I W X 101-0 PM Owner's Name A L l� OM EW ... Address Q�l� (� I • �z`®� Phone — a' r Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ " SYSTEM REPAIR ❑ OTHER ED }� DISTANCE TO'NEAREST: SEPTIC TANK' SE '"`"'WER LINES `" `DISPOSAL FLD---40 PROP. LIN FOUNDATION AGRICULTURE WELL OTHER WELL /SUMPS =� , '- j INTENDED USE TYPE OF WELL PROtBLEM AREA CONSTRUCTION SPECIFI C3NS { ❑ Industrial. ❑ Open Bottom ❑ Manteca Dia. of W mon Dia. of Well Casing ❑ Domestic/,Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications. M Public ❑ Other elta Depth of Grout Seal Type of Grout _ I I Irrigation rox. Depth i I Eastern Surface Seal Installed by _ Repair Work Don Type of Pump �' H.P. State Work Done_ Well De tion ❑ Well Diameter Sealing Material (top 50') I (' § Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION f I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence��Commercials'_ Other Y Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK De Type/Mfg F Capacity No. Compartments PKG. TREATMENT-PCT.O -" T"%" Method of Disposal Distance to nearest: Well Foundation i C LEACHING LINE++ rp ❑`'�WNo.A& Length of lines Total length/size FILTER BED i ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I ;,Depth` * Size Number SUMPS 0 'Distance to nearest: Well Foundation Property Line V DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in a Lordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 3 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 employ persons subject to workman's compensa- tion laws of California:" The applicant s for all r quire s ctions. Com ete drawing on reverse side. F Signed X i _ _ _ Title: Date: F DEPARTMENT"LISE ONLY Application Accepted,by"' CH Date Area j Pit or Grout Inspection y. Date Final Inspection Date�� Z 1 A I I { Additional Comments: 1R` 14 ❑ 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 95201E N IFEE NFO AMOUNT DUE ' Rs. AMOUNT REMITTED ``CK 'RECEIVED BY i DATE PERMIT'NO. + EH 13-24 IRE EH 14-26 /