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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Ao� i. ,. 1601 E. HAZE�TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATEISSUED (Complete in Tripkate) +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 Ryles and Regulations of the San Joaquin Local Health District. _ �. r. .� PM,, y , Job Address J �i Com! 134 r.675; � ��ity �%�A• � Y Lot Size f'�" A7r� Owner's Name" _��1'. /e- Address 161A Na KTX G', Phone " — Contractor ., . �uGGc' Address l ' License No. g; 5P 2 Phone 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of.Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth.of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter Sealing'Material {top 501 DepthFiller Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 available within 200 feet.) installation will serve: Residence, G,11minercial Other-t- '- '"'- - .x .. Number of living units: ....___ -Number of bedrooms Character of soil to a depth of 3 feet: Water table depth—36 SEPTIC TANK q$` Type/Mfg a Capacity ,eJ9zfNo. Compartments PKG. TREATMENT PLT. ❑ Y " Imo '~. fir -- Method of Disposal ' Distance to nearest: W�ellI leo _Foundation .Property Line 1 VVVV G LEACHING LINE " �'� '�I� No�& Length i'ofsfines �"' � � _ Total'length/size• FILTER BED ❑ Distance to nearest: Well r+Foundation `Property Line SEEPAGE P_JTS ^"`- ❑ Depth �T -Size l/� ' t• /,t L�OT� ...�.-. .Numbers _.,.,., SUMPS IX Distance to nearest: Well Foundation*�Propertyel`Line DISPOSAL PONDS ' ❑ r t } I hereby certjfythat I have prepared this application and that the"work'wiII bezlone`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 noir employ any person in such manner-as-to becbr6 subject to°workman's compensation laws of California."Contractor's hiring or subrcontracting signature) certifies the following:'`l certify ikat in'the performance of the work for which this permit is issued, I shall employ,persons subject to workr4ian's compensa- tion laws of Califomia1`.. 3i "l } The applicant mcall for II r' iretl inspections)Complete drawing`on reverse side. A� _ Signed X :�7�r_� N- Title: c. �� Date: 3 FOR DEPAiiTMENT-USE ONLY Application Accepted by Date /� T Area ©7 Pit or Grout inspection by T l Date - Final inspection by Date Additional Comments: Q� 1 . iC ❑ 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' gMOUNT DUE A fi OUNT'REl11lIT EDe CK# -�RE6EWED-BY+�-- DATE O "�. '" 'CASH ;. + EH 13-24(REV.1,1) /'•7 �� - 4 W EH 1426 11/ S t