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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT (� 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. Job Address I ) Al(Z '\� (.v/� City rn NCO Lot Size X70 'fC PM Owner's Name t l C I/'�,A Address (� S 9 (R 10®<T'iA/A Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT- ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK '�" SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 2-Manteca Dia. of Well Excavation Dia. of Well Casing .Domestic/Private EI-Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 !' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is availably i feral.` Installation will serve: Residence�/ Commercial_ Other Number of living units: Number of bedrooms y �"`�1?l /L' �® �4 Character of soil to a depth of 3 feet: 3 Ig W O Water table depth SEPTIC TANK -Z Type/Mfg Z^ Capacity 12-0 O No. Compartments �- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well /it, /o Foundation ! 0 /-7" Property Line f LEACHING LINE No. & Length of lines U � Tgtal-length/size FILTER BED ❑ Distance to nearest: Well� Foundation /7 Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 7C 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 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 for all required in pections. Complete drawing on reverse side. Signed Title: t51Ltn-t� Date: DEPARTMENT USE ONLY Application Accepted by v Date -' Area Pit or Grout Inspection by Date Final Inspection by Date 47 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 lcmanteca 823-7104 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental 4eal'bu Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO + EH 13-24 71 (REV.1/95) /� �" —7©` e1 �S �/� ,,,C� EH 14-28 v