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APPLICATION FOR PERMIT d- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA . Telephone {209} 466-6781 h PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in,Triplicate) Application is hereby made to the Sand 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. Job Address 76 S � .i;e 114vx 1.2,0 City_9i;:9dJ Lot Size daa + PM f a Owner's Name Y, dC\ Address IV O 2 t YwY—/zQ Phone r :� Contractor �� Address License No. Phone_ i TYPE OF WELL/PUMP: :.NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OP, WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4t'` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 M Public (7 Other,r ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation ---Approx. Depth I I 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 f Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION I I DESTRUCTION ( I (No septic system permitted if public sewer is -1 available within 200 feet.) f Installation will serve: Residence—' Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 63' Type/Mfg _C_< l- _o_t4',0 Capacity 40 No. Compartments PKG. TREATMENT PLT. Cl 1 �r Method of Disposal Distance to nearest: Well / Foundation 70 Property Line 3c, C LEACHING LINE No. & Length of lines U Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation v Property Line C1 ( SEEPAGE PITS �4__ Depth�_ Size 0 Z _ Number RUM4- DrM7ance to nearest: Well /7S' Foundation 7 C, Property Line-' G DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with n Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di3trict. 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 shalt 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." The applicant must call fir all reT ed ins tions. Complete drawing on reverse side. Signed Xy'tr / Title: T IQwft G� Date: ' FOR DEPARTMENT USE ONLY Application Accepted by i�,�P , � Date rea Pit or Grout Inspection by Date Final Inspection by Date�� Additional Comments: r /Z ❑ Stk 466-6781 • ❑ 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 r FEE F INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 1�241REV.t/H5Y �U 76 r 01.3 y EH 14-2a .