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a p APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) . . Application is heieby 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 Cou ty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /p / ;.0 Job Address 9f C /'Po city AoK C4 Lot Size PM Owner's Mame T ��v Rddress { Phone b � Contrac or Address re a=USXr� __ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - PUMP INSTALLATION LJ ' SYSTEM-REPAIR-171OTHER ❑ DISTANCE TO NEAREST:,SEPTIC'TANK{ SEWER LINES' ,- DISPOSAL FLD- PROP. LINE FOUNDATIONII A AGRICULTURE WELL OTHER WELL PITS/SUMPS _ i INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS $ ❑ Industrial ❑,Open'Bottom ❑ Manteca "Dia, of Well Excavation r Dia. of Well Casing * Domestic/Private L1 Gravel Pack ❑ Tracy Type of Casing Specifications Q (•1 Public •�n-Other s .' n Delta Depth of Grout Seal Type of Grout _. Q I I Irrigation _-prox. Depth l l Eastern Surface Seal Installed by - r Repair Work Done ❑ Type of Pump H.P. State Work Done— Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth —filter-Material (Below 501 -- ; TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION l I Wo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial``�Other�E'/ + �' Number of living units: Numbec.of bedrooms' Character of soil to a depth of 3 feet: r s "'� Water tabledepth SEPTIC TANK Q` Type/MfgL20121")-r- 1p1city 6WQ No. Compartments 1 PKG. TREATMENT PLT. ❑ y lee L �s IV th�od�,of0ispostal + Distance to nearest: Well Foundation Property Line ; y] -- ,,.�n.w ,1�� _ .--....._ �.�•sYaw�rir �1'K ear � - �- .maw-.�-TA's�.�_^aw'�s.+�w•+w•�`1_ 1 1 LEACHING LINE A-`No- & Length of lines J Total length/size ©o FILTER BED ❑ Distance to nearest: Well Foundation Property Line a SEEPAGE PITS 1 I pth Size` Number SUMPS Distance to nearest: r Foundation 42 Property Line ra - DISPOSAL PONDS ❑ 1 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 anner as to become subject.to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I rtify that in the pelf ance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ..+' eA I i The applicant mus for all requir spectio C- lete drawing on reverse side. 1 Sig d Title: _ Date: , FOR DEP TMENT USE ONLY Application Accepted by dDate Area !U Pit orGrout Inspection by p� bateFinal Inspection by Date Additional Comments: A '� i.AW ' ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83 6385 Y _117 .7r-,(.�, AIIC d, { Applicant_Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,_P:O. Bax 2009, Stk., CA.95201„ ._ , 4,17—C— I i FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY A DATE jPEMIT'NO. vvv ! ♦ EH 13.24(REV.i I H e) /) // EH 14-26 c) - .