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f APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 3 YEAR FROM DATE ISSUED 4 (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. 1 Job Address _ �(flT�.. �. 0 City Lot Size oto -f- PM Owner's Name t Address Jif //�� r Phone _ /_�{_ ' Contractor_ 13ty d6A1-.,1ir Address 3'Le�/e /FA1GAeL — 7/ e License No. Y Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D i - DIS TAN GE.T-O-N EAR EST•TSEPT.IC TANK, _SEWER_LINES _ DISPOSAL_FLD. PROP�LINE_�^ FOUNDATION AGRICULTURE WELL OTHER WELL r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial b Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 1A. ❑ Tracy ., Type of casing Specifications W 1-1 Puhlic F, Other } F.1 pelta Depth of Grout Seal f Type of Grout _ I I Irrigation __Approx?pepth„ RI'7 Easter urfae SSaI"tn�tailed by f r . Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'} Depth ;+- Filler Material (Below 501 f I v I TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION I I (No septic system permined if public sewer is available Wittiin`20(Neet./ '^ a Installation will serve: _ Residence�� Commercial— Other � � � Number of living units: _;Z— Number of bedrooms Character of soil to a depth of 3 feet: zw i _Water table depth ' SEPTIC TANK ❑ Type/Mfg I i Capacity No. Compartments e ' PKG.KG. TREATME=NT PLT. ❑ I I 1 ' _ Method of Disposal Distance to nearest: Well 6a— Foundation--,L�d Peroperty line — ` I I / \1 LEACHING LINE " , ❑ No. & Length of lines '`!iO Total length/size FILTER BED ❑ Distance I to nearest: Well1100 r F&ndSbd-6--. - a —°PPopeity`L'irie ,� f SEEPAGE PITS I I Depth z Size Number UM t_1 Distance to',nearest: Well �.7s, Foundation Property Line DISPOSAL PONDS 11I I hereby certify that ihave 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 Di§trict. 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 sh 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: all not certify that in the�performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of Calif ophfa I }} /� �12d I. The applicant mu.. �;..3i� d.insoectians. Complete drawing an reverse side. Signed X� Title: © C L 79 FOR DEPARTMENT USE ONLY g i Application Accepted by Date ! t Area Pit or Grout Inspection by1 Date Final Inspection by i I Date Additional Comments: ❑ Stk 486-6781 0 Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies tri: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0, Box 2009, Stk., CA 95201; '} 4 t FEE 1 AMOUNT DUE INFO AMOUNT REMITTED CK RECEIVED BY CASH DATE PERMIT'NO. ( _ I ♦.EH 13-21(REV.t/ti 5) EH 11-28 I 1 I