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yt APPLICATION FOR PERMIT (a;Do Noah/ s SAN JOAQUIN. LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ;PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 11. (Complete in Triplicate) Application is hereby made to the San Joahuin 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. r\Job Address I.)– 1 ' City Lot Size PM :I Owner's Name e Address 22 v Phone Z, � Contractor _� t7 fl�� ' Addres License N Phone TYPE OF WELL/PUMP: NEW WELL ❑ ELL REPLACE ENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM EPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUR W LL OTHER WELL PITS/SUMPS INTENDED USE ❑ Industrial ❑ Domestic/ Private f"1 Public I I Irrigation Repair Work Done ❑ Well Destruction ❑ TYPE OF WELL PROBLEM AREA ❑ Open Bottom ' ❑ Manteca ❑ Gravel Pack ❑ Tracy f-1 Other (1 Delta —,-Approx. Depth I I Eastern Type of Pump I H. Well Diameter. +I Depth � } TRUCTION SPECIFICATIONS Well Excavation Depth of Surface ut Seal Installed by State Work Done ;realing Material (top 50') 1 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] R PAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _' Commercial _ Other �Choo Number of living units: Number of bedroo s i t, Character of soil to a depth of 3 feet: f ` Water table depth -3,77 co SEPTIC TANK O Type/Mfg' r Capacity No. Compartments `"''� PKG. TREATMENT PLT. ❑ I Method of Disposal 1. +,, Distance to'nearest: Well Foundation Property Line Dia. of Well Casing Specifications Type of Grout-- LEACHING rout__ LEACHING LINE c-r—No. & Length of lines w� Total length/size FILTER BED ❑ Distance 6o nearest: Well Foundatio Property Line SEEPAGE PITS I I e Size _Number SUMPS Ll i tance to` nearest: Well , Foundation Property Line DISPOSAL PONDS i I hereby certify that I have prepared his application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and —rUfes 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 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." 1 The applicant mus forallre u ms ons. Complete drawing on reverse side. + Signed X /[.1/!/ �� Title: _5 C9 Date: I `o OR DEPARTMENT USE ONLY Application Accepted by Date 3- D Area Pit or Grout Inspection by ` Dat Fin@( Inspection by Dat t\ — (1 — (_� � Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 Manteca -7104 ❑ Tracy 835-6385- Applicant 35.6385Applicant - Return all copies to: Environm{ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i +. EH 13-24 (REV. I/ n 5 EH U -2a FEE INFO*AMOUNT DUE I AMOUNT REMITTED CASH cK RECEIVED BY DATE PERMIT'NO. (9.( I 70