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5 APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA M Telephone (209) 466-6781 l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - (Corrlplete 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 Districctt� jj / /� i Job Address / 66 A s WkgeK (/GrY . - City Lot Size } I PIVD F ft Owner's Name _ I/I�CP,n Address S, Phone g 3 va r _ Contractor [. Address License No& Phone G 93.F33 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO'jVEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 n Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth l-1 Eastern Surface Seal Installed by I _,,.-Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material !Below 501 � y r TYPE OF SEPTIC WORK: NEW INSTALLATION Of REPAIR/ADDITION l l DESTRUCTION I i lNo septic system permitted if public sewer r available within 200 feet.) {,� Installation will serve: Residence_ Commercial_ Other W Number of living units: -j— Number of bedrooms 3 r Character of soil to a depth of 3 feet: 1b�� Water table depth SEPTIC TANK i1/Type/Mfg. �t - '("+ G Capacity lk(A No. Compartments 2 PKG. TREATMENT PLT. ❑ x ✓fir f f Method of Disposal Distance to nearest: Well Foundation Property Line.,2D2 4 LEACHING LINE C41-No. & Length of lines is?_2 y� s Total length/size r FILTER BED ❑ Distance to nearest: Well-lam --- Foundation Property Line ` k SEEPAGE PITS Ak'Depth d Size Number SUMPS Ll Distance to nearest: Well 1s� '' Foundation �.t Property Line �r I 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 i 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 compensar tion laws of California.", i'-. 1 q The applicant rust call f al equired inspections. Complete drawing on reverse side. s Signed X - Title: LJ 6u'ye-4 „-_ Date: 'e�S t FOR DEPARTMENT USE ONLY j Application Accepted by Date � Area 3 i or Grout Inspection by Date f=: Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 FEE d INFO AMOUNT DUE AMOUNT REMITTED C CK SH RECEIVED BY DATE PERMIT'NO. r-EH 1324(REV.;/A 5) �� 7V ___1EH 14.26 0 a ��