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APPLICATION..FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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 sLocai Health District. I I Job Address City�?� (5N/1?o0 Lot Size PM i Owner's Name / i47%eM G71%95 Address yRO' YD'T r V&)r Phone OF 17 Contractor 7_ O/r3` O/V Address -106A B L v to vM i4AFf License Na. yyy��f Phonex —yid� ----TYPE OF WELL/PUMP•:_..,,�NEW:WELL_❑ -,.WELL REP LACEMENTjQ.J_:i�DESTRUCTION ❑_ � I. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ T DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE —FOUNDATION ,AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ,` PROBLEM-AREA-a CONSTRUCTION-SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of W6II Excavation Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy. Type of Casing Specifications f l Public 171 Other Cl.pelta Depth of Grout Seal- . --Type of.Grout \ i I Irrigation ---Approx. Depth' l 1 Eastern Surface Sedl installed by Repair Work Done ❑ Type of Pump = H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth r Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION VT REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) IN Installation will serve: Residence_ rCom'mercial_ =Other FId b!t No" tr Number of living units: -Number'.of bedrooms Character of soil to a depth of 3 feet: ✓`AM i Water table depth ! SEPTIC TANK B Type/Mfg ge C.43 Ir P4 t- Capacity»?x0.17 PKG. TREATMENT PLT. ❑ t ..��w_t Method of Disposal Distance to nearest: Well Foundation 5 Property Line 11" LEACHING LINE ❑ No. & Length of lines Total length/size '1,70 FILTER BED B Distance to nearest: Welles Foundation ®� Property Line d SEEPAGE PITS i l Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ a 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, ait' rules and regulations of the San Joaquin Local Health Diktrict. \ " 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 call for all required inspections. Complete drawing on reverse side. 4 F Signed X Title: Date: J--A/ 9'0 I FOR DEPARTMENT USE ONLY Application Accepted by bate �'L Area r Pit or Grout Inspection by Date Final Inspection by Date u" C D 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 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO CASH DATE PERMIT'NO. ' -(REV.1/x 5) -� o-