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# a ` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED r (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 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 District. f ti� (jL� Q /� *City Lot Size 5�c_ PM Job Address , I Owner's Name a G Address z 7 yy/ da Gosrx ---- Phone { y j Contractor Address �C tti�� License No. 30 J-7�/ Phone 3 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 I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _ + 1 ❑ Domestic/Private w ❑ Gravel Pack ❑ Tracy Type of Casing Specifications {- f'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout-Z tR, I I Irritation- _Approx. Depth [ I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction t - Well Diaineter- Sealing Material Ltop 50') Depth Filler Material Melow 501 k TYPE OF SEPTIC WORK: NEW INSTALLATION W' REPAIR/ADDITION LI DESTRUCTION l I INo septic system permitted if public sewer is 1 available within 200 feet.) f C t I Installation will serve: Residence Commercial_ Other t Number of living units: Number ofooms 3 C� f � Character of soil to a depth of 3 feet: Water table depth 949 , SEPTIC TANK L!T"Type/Mfg Capacity 1600 No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal j f Distance to nearest: Well f Foundation Q t Property Line LEACHING LINE P'�No. & Length of lines 3 1 VQ f Total length/size �� ! FILTER :BED ❑ Distance to nearest: Well d t Foundation �O f Property Line 7b f SEEPAGE PITS M"' Depth a r Size 3 160 it - - -Number SUMPS L-1 Distance to nearest: Well Foundation �7 t Property Line f f, DISPOSAL PONDS ❑ hereby certify that I have prepared this application-and that the work will be done`in-accordance with San Joaquin,.couA y 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 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." 4 The applicant must call for all equired inspections. Complete drawing on reverse side. Signed X Title: Gf� O-et Date: FOR DEPARTMENT USE ONLY j v Application Accepted byDate �O �e� Y Area 77 I Pi r Grout Inspectio Date Final inspection by fi Dat,2- Additional Comments: ❑ Stk `456 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 1 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNO. INFO r� CASH J , + EH 14.26 REV,s i n s) -7 Q o U 11003 _ZB��$ EH 14-2e ll I J v 1