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-r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA r�r] Telephone A(209) 466-6781 [� F '4 „'?4 } `��••�i� .t. v � � ^�dc '�- +ice Y':. � PERMIT EXPIRES 1 YEAR FROM .DATE.ISSUED:,%0 , �x (Complete in Triplicate) . .t; 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 Ragulations of the San Joaquin Local Health District. Job Address Z V-,V75,1 �� _ City�Or��.�Lot Size zS�.�Cr,e PM _ 4 - _ - _n - 46 X' SIS Phone Owner's Name ��e.vi^�nfi Address Contractor's Name �e/ License No. Phone 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 �. FOUNDATION AGRICULTURE WELL OTHER WELL_ Pfi"S/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casin1- d ❑ 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 Well Destruction ❑ Well Diameter Sealing Material (top 507 Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATIO" REPAIR/ADDITION DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence ,Commercial— Other Number of living units: j_ Number of bedrooms �3. A;'Z'c 1 - Character of soil to a depth of 3 feet: C rc L- I Water table depth ®A" SEPTIC TANK X Type/Mfg _� h,u•Y s Sc.0206"c. TG"k Capacity s /No. Compartments 2- PKG. TREATMENT PLT. ❑ /arc CasT Lndr' Method of Disposal Lead r r Distance to nearest: Well rJ� Foundation 01D op Property Line 3�Q LEACHING LINE 6 Nth B�rLliiO'of lines3 -i1a�S 80ft"e�c� Total length/size F1LTEA BED , istance to nearest:- . Well 4 f ..Foundation K/©"Y k, _ Property Line✓�ao�'� ' SEEPAGE PITS ❑ Depth Size ' „� 4. Number k ISUMPS ❑ Distance to nearest:. Well —Foundation ” Property Lined DISPOSAL PONDS ❑ + tY '" I hereby certify that I have prepared this application and that the work will be'cibhe.in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. f3 - ! 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subiect to-workman's compensa- tion laws of California." - The applicant must call for all required inspections. Complete drawing on reverse side. T Signed X itle �- Q»ALA1^ .^ ; Date::.... '_/ -��y FOR DEPART ENT TSE ONLY f y , i Application Accepted by Date rea 0,12 Pit or Grout Inspection by Date Final In action by i Date r_J/ Additional Comments: 0.0Z ❑ Stk 466-Ml Lodi 369-3621 ❑ teca 823-7104 ClT acy 835-6385 - Applicant- Return all copies to: Environmental Healt Permit/Services.1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 } H } FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. y INFO CASH S 8� WJE `7—(�-- ., Sof-.�- . . . . + - +EH 13-24(REV.10!83) i EH 14-26.