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9 7 APPLICATION FOR PERMIT SAN. JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Q Telephone (209) 466-6781 IT EXPIRES 1 YEAR FROM DATE ISSUE PERM JUN (Complete in Triplicate) �Sp�p_�7__ 1. 6 l 8 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instbl herein descrihd. This application is, App E*Nt 1pions of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and t MITlSiERV &4trH Local Health District, " ' ice i . .�}`.5'[e�'��=`r'�` - . 'I' �" �f rc,�.��•�l� 5 Peen L' — 7�Z City Lot Size Job Address Owner's Name �: .fir! °� "m.• Address / Phone " 7 7 Contractor /1(�!Z ! 5� Address a?S S -_41a 'X t license No. • —Phone_ TYPE OF WELL/PUMP: trNEW WELL ElWELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 15-0 If SEWER LINES DISPOSAL FLD./sa' PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LlIndustrial C1Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing DomJ. estic/Private )7i Gravel Pack ❑ Tracy Type of Casing Specifications 1 l`7 Public Ll Other Cl Delta X Depth of Grout Seal ADD Type of Grout - I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done LJType of Pump W.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 C__ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION l I DESTRUCTION i 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— .Commercial— Other Number of living units: Number of bedrooms �5 Character of soil to a depth of 3 feet: Water table depth rp t.0� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ tax r Method of Disposal W_ � --t k Distance to nearest: Well Foundation Property.Line Z tw LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number U4 SUMPS Ll Distance to nearest: Well Foundation Property Line __DISPOSAL PONDS ❑ _. _ __- __-� f 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 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 Fpust call for all requir inspections. omplete drawing n (ev rse side. Signed X Title: V Date: l FO PA T T USE ONLY Application Accepted by Date b -� V._ r �� eJFG4GGvzzTO ��/ Pit or Grout Inspection by Date Final Inspection bysPEc " J Data f� �p0 rr5 Wjrrr 8Ex;7D,"I,r;f-7 Additional Comments: "'�r r' > n Q Lv ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 - Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Aye, P. Box 2008 Stk., CA95 01 `f�r 414a- t�� f ,.syr ILed 6� 5 �er �w 5I z 6� P ew.1e v wit la�6Cce� : 1 #35�•� r �'w FEE ✓ � IN AMOUNT DUE AMOUNT REMITTED GK RECEIVED BY DATE PERMIT *.EH 13241REV.riK51 I � EH 14-26