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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 (a l� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .N", )L x (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 San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made compliancehereby ma Local Health District. +� 3 Job Address 3 03T% " f�Yd City 7; _ Lot Size �19CY�s' PM Owner's Name Address ✓� �� r� ��/ Phone /_' Sew License No. Phone Contractor's Name N W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: SYSTEK4'REPAIR ❑ OTHER ❑ .-"—PUMFINSTALLATION'❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I DISPOSAL FLD. PROP. LINE PITS/SUMPS I FOUNDATION AGRICULTURE WELL ! OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C3 Industrial � ❑Open Bottom O Manteca Dia, of Well Excavation Dia. of Well Casing E3 Domestic/ Private El Gravel Pack Type of Casing ❑ Tracy Yp g Depth of Grout Seal Specifications Type of Grout— YP El Public ❑ Other ❑ Delta ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work,Done ❑ Type of Pump H. P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth ' � Filler Material {Below 50'1 stm tted TYPE OF, SEPTIC WORK: NEW -INSTALLATION LJ -,REPAIR /ADDITION DESTRUCTION ❑ aNailablpe�with ne200 feet.) Installation will serve: Residence � f Commercial Other Number of living units: --L'�� Number of bedrooms .:�?- , V Character of soil to a depth of 3 feet: S .�/— � ! - �4 Water table depth SEPTIC TANK [I _Type/ Mfg C „� `jr Tsis7� Capacity /600 No. Compartments Method of Disposal PKG, TREATMENT PLT. El Distance to nearest: Well Foundation /0 ' Property Line `- ,Sri LEACHING LINE 91_No. &Length of lines Total -length ,- _. _/size »0 _ FILTER BED m El Distance to nearest: Well �� Foundation Property Line SEEPAGE PITS SUMPS ❑ Depth �a - , ,Size i$ Distance to nearest: Well ,,LfiafLyX� .Number ^.'�\ - -.< lFoundation �� Property Line /ori public sewer is r 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_owneror licensed agent's signature certifies the following: "I car*that in the performance of the work for which this permit is issued, !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." It , The applicant must call for all required inspections. Complete drawing on reverse side. R Signed "r.P Title: Date: --y g f } FOR DEPARTMENT USE ONLY % r f Ares 6 Application Accepted by <' i Date Date L Pit or Grout Inspection by Date Final Inspection by i-3 1 a ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - ❑ Tracy 835-6385 Applicant - Refurn-all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t 7 FEE CK RECEIVED BY DATE PERMIT NO. INFO AMOUNT DUE AMOUNT REMITTED ^p CASH + EH 1344 (REV. 16/831 dfl 12�3l8 c �` EH W28 _. C/� VV 0 KY I