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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I Application is hereby made to the Sari-Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is [ made in compliance with Sari Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin f Local Health District. Job Address City Lot Size PM Owner's Name JjLL' +� �� r Address �'��1 ��h� �r 1��'t� Phone ��4 t � + Contractor r ` iz` r �� t-{!� Address u" ` ��'`'" !!ti License No. �33�F'71Phone J -6'V TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i C}l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ - OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL, r PROBLEM AREA CONSTRUCTION SPECIFICATIONS I_ C} Industrial .17-1 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f`1 Public f.l Other (} pelta Depth of Grout Seal T ! qu e P Type of Grout Irrigation Approx.IDepth. I I Eastern Surface Seal Installed by # Repair Work Done 13 Type of Pump H.P. State Work Done ` Well Destruction ❑ Well DiameterMdealing Material flop (`i t Depth. Filler Madrial (Below.1501) t '�t TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDI-1ION l I ITESTRUCTION I-i (No septic system,permitted if public sewer is �Q S ¢ available within 200 feet.) Installation will serve: Residence Commercial Other -- -.sit. ' k Number of living units: �_ Number of bedroom + Character of soil to a depth of 3 feet: -' x a r p Water table depth r I SEPTIC TANK Type/Mfg,. r fi X Capacity No. Compartments 1-_7A I PKG, TREATMENT PLT- ❑. s al . -, _ Method of Disposal Distance to,,nearest: WI ?,. Foi undation"fU Property Line t. LEACHING LINE No. & Length of lines k� Total kerigth/site �� Z FILTER BED CI Distance to nearest: W F�iifid'ati6rY 'b " •"" �o`perly Line ` SEEPAGE PITS Depth -2Size ' _ Number _ T` SUMPS LI Distance tottnearest: Well Foundation Property Line 1 DISPOSAL PONDS O 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 taws, and t rules and regulations of the San Joaquin Local Health Di'Wict. . 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 law s of California."Contractor's hiring or sub-contracting signature i 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 applic t I t al �uued•inspectio� pmplete drawing on r vers side. *Signed X s.7L1 Title: _ !-Z -11 Date: _ i FOR DEPARTMENT USE ONLY Application Accepted by Date Area 9�or Grout Inspection by Date< Final Inspection bY� J T)atU Additional Comments: S e a ❑ Stk 466-6781 El Lodi 369-3621 . ❑ Manteca 823.7144 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE pERMiT NO. . . Er;a-2e. t-H 13-24(REV.I/n 51 M