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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1.601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED IComplete in Triplicate) r 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 iC S _. City Lot Size PM Owner's Name TO& L&4r-r 50V Address C /" J-4'"6 Phone Contractor .Z` C. Address 3 /d /V• �� icense No. r �� Phone 466 bb TYPE OF WELL/PUMP: I 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ; O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing `' Specifications ❑ Public ❑ Other F1 Delta Depth of Grout Se61Type of Grout I I Irrigation .-Approx. Depth l I Eastern Surface Seal Insta.114byy i Repair Work Done .❑ Type of Pump H.P. Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 t- TYPE OF SEPTIC WORK: NEW INSTALLATION Wo'REPAIR/ADDITION l 1 DESTRUCTION I No septic system permitted if public sewer is 1 OC]n I ? available within.200 feet.l Installation will serve: Residence-Ie Commercial_._ Other ` E n �, /;C �. � PC' Number of living units: �_ Number of bedrooms; Character of soil to a depth of 3 feet: N Water table'depth -SEPTIC TANK L9" Type/Mfg _-�n'L/Gw4'f� Ca acit Z lld` ` ' * P y a. No. Compartments PKG. TREATMENT PLT. ❑ ay Method of Disposal Distance to nearest: yS Well _fD� �-F Foundation_-�.._-_ Property Line LEACHING LINE W-No. Length of lines t �` YQ ) 0 ' - � Total length/size O • Z )4 FILTER BED ❑ Distance to nearest: Well ��,F. Foundationproperty Line SEEPAGE PITS , IfY'Depth Zs r Size — *r — � Numbers SUMPS Ll Distance to nearest:_ Well !-4 Foundations s 1_ Rroperty Line00, DISPOSAL PONDS ❑ .' 1 l O t 1 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 rules and regulations of the San Joaquin Local Health-Di'strict. 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.'4 Contractors hiring or sub-contracting signature certifies the following: "I certify that in.the•performance of the work�fcir 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 inspections. Complete drawing on reverse side. i s Signed 7 Title: Date: d FOR DEPARTMENT USE ONLY Application-Accepted bypaiaT +'��U Araa t J i or Grout Inspection byDatet ..-_ Final lnspection,by ._ - Date Additional Comments: -.-t " f � z— ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009,$tk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT NO. r EH 13-24(REV.1iKS) -0 v / EH 14-26 111 a-J