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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEI_TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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. t/�G a p of Size PM Job Address iC. City Owner's Name r t`► �! Address Phone I, d: G .x 'T _ �.License'No ':S3��oc "Phone � `oritractor �'Z-_ rZE7 - Address i TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ L. I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public n Other ❑ Delta Depth of Grout Seal Type of Grout - I I Irrigation Approx.A rox. Depth I 1 Eastern Surface Seal Installed by - Repair-Work Done 0 Type of Pump H.P. State,Work Done _ t Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 - 5 - TYPE OF SEPTIC WORK: NEW-INSTALLATION V- REPAIR/ADDITION I 1 DESTRUCTION I I INo septic 'system permitted'if public sewer is available within 200 fee4.) � 4 Installation will serve: Residence Commercial Other Number of living units: --I- Number of bedrooms 13 �4 , a 4 c Character of soil to a depth of 3 feet: -" "��'b -'F' % - -J~ Water table depth SEPTIC TANK "O> Type/Mfg Capacity��LNo. Compartments T ❑ � �. T - f. Method of Disposal PKG. TREATMENT PL t Distance to nearest: Well_ Foundation Property Line� r l LEACHING LINE } , No. &.1-c"" ngth of lines Total length/size FILTER BED D *Distance to nearest: Well 110 Foundation 'Property Line 45 U-t- C' t o i SEEPAGE PITS f l lP Depth -ZEF 21 Size «- r Number SUMPS -Dislatice to nearest: Well&0�PFoundation 7-Property Line DISPOSAL PONDS: 0; 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�flie San Joaquin Local Health DFstrict.E 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 shali not . employ any person in such manner as to become subject to workman's compensation laws of-California." Contractors hiring or sub-contracting signature certifies the following: "/certify that in the performance of the''work for which this permit is issued,'(shall:employ persons subject to workman's compensa- Y tion laws of California.'J"' The applicant must call'for require inspections. Complete drawing on reverse side. F _ Signed X y �`._ Title: s.« .� �� _ Date: '" FOR DEPAR ENT USE ONLY . Application Accepted by Date `� Area Pit or Grout Inspection by Date "Final Inspection by Date-� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 363-3621= ❑`MaYtteca 823=7104' r'."❑ Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201Y t IFEE NFO AMOUNT•DUE. AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24 IREV.i i H sl Q �.�..:...,.�+.+.+- __>.." - -^'•..•",_.._.m......^,.,.,-....-_�..,_.- .-».....x-.w,.- . - _� Eli 14.28