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APPLICATION FOR PERMIT AT\\ SAN JOAQUIN LOCAL HEALTH DISTRICT � 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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 + E City :t 5C,5f0/I Lot Size PM ' Owner's Name Address Address 5�,,►-t-� Phone Contractor_ ` �FCJ1 ��y Address © License No. ' Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM.R.EPAIR.El. OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE jTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O,Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public n Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation i—.-Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to-a de th of 3 feet: "Ws 0&-in '"`' ' Water table depth SEPTIC TANK Type/Mfg's 4 L. ccs6ccp iwe-Capacity L A hNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r r .fTPI Distance to nearest: Well Foundation Property Line�_ i LEACHING LINE kl . No. & Length of line. Total length/size a '" FILTER BED ❑ '. Distance to nearest: Well- Foundation AS�`� Property Line )/ SEEPAGE PITS i I ' Depth i f Size �D _ Number c�L SUMPS % /Distance to nearest: „W611 _ Foundation s 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 must callor all requi ed inAspections. Complete drawing on reverse side. Signed X - OA,, /z'v ,{jec/ Title: [ ��Vl- w Date: Q SPARTMENT USE ONLY Application Acceptedby. "` Date Area Pit or Grout Inspection by Date > •Final Inspection by Date 1 Additional Comments:, ,- 1 - - r - - ...-.,,-_ , w , ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK _ RECEIVED 8Y FEEDATE ak PERMIT NO. +.EH13-24(REV.1 i 8 sl _ -7