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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) - t. ` Aplication 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 p k ounty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rples and Regu made in compliance with San Joaquin Clations of the San Joaquin Local Health District. t � l �s eI✓fY yN. ?� Cit}, „ICSC.A LAN )Lot Size PM V P 4- Job Address w ` L 9E+►�4C. -- - Phone Owner's Name T3. go C R A Address T/y�rTf�a/�' -0 Svc Address s" License,Nov yyY_ �� Phone Contractor TION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTT� R �-1^��`��,. SY.ST.EM..REP.AIRm❑-. - --SDI DISPOSAL FLD. PRQP._LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ - a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` ❑ Open Bottom ❑ Manteca Dia. of Well Exca�ationt - Dia.of Well Casing ❑ Industrial �``" E t[t + '• Specifications ❑ DomesticlPrivate ❑Gravel Pack ❑ Type of Casing Tracy T4 a of Grout 11 Public -�-r El Other _� Delta,._! Depth of Grout Seal }p © Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by— State y ` rs k H p State Work Done Repair Work Done: !❑ Type of Pump Sealing Material [top 501 ¢`` Well Destruction ❑ Well Diameter 9 Depth A '� ` kFiller Material Below 50') �1 TYPE OF SEPTIC iWORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ iNo-septic system permitted if public sewer is 1 �--•�� '`""a%iailable within 200 feet.) l Installation will serve: Residence X Commercial_ Other1=111— E� 1 . Number of living units: Number of bedrooms Character of soil,to a depth of 3 feet: Cl / Water.t66le,`depth Y No. Compartments SEPTIC TANK ElType/Mfg capacity * W Method of Dispdsal PKG, TREATMENT PLT. ❑ Distance to nearest: Well y .{Foundation Property Line w_l a: �^-�F� �O' Total lerigthlsize LEACHING LINE No. & Length of lines _ . -fa FILTER BED ❑ Distance to nearest: well Foundation Foundation �/b * operty Lin NLA 4: -YX I��'A / d Numbers t i SEEPAGE PITS ❑ Depth Size SUMPS i Distance,tto nearest: Well ides �n Foundation `''Qraperty-Line i DISPOSAL PONDS Q t � R 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: F Home owner or licensed ag`ent'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 uch manner as to become subject to workman's compensation laws of California."Contractors hiring or sub contracting signature certifies the followirr'g:"I certify that in the performance of the work for which his permit is issued,I shall employ persons subject to workman's compensa tion laws of California." 0 . The applicantmust call for all required ins_ctions. C_orrlplete-drawing o_I-Verse side. r Title: x Date: 8-'6d Signed X # ~" iL} EOR/DEPARTMENT USE ONLY . if7 Date Area O Application Accepted by Final Inspection by Date Pit or Grout Inspection by Date r.. , r�x Additional Comments: ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 83--6385 x Applicant-'Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK* RECEIVED BY DATE PERMIT"NO. 1 INFO AMOUNT DUE . AMOUNT REMITTED CASH i. + EH 1426 EH 13-24 IREV.1/851 � t�n 0 , .