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F { APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON 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 l 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 _� V Q 700,.". +F 1 �e r do City I' `00n Lot Size acre PM i Owner's Name Browns !�W\� Address } P Phone Contractor (1�1�1�If' Address S LZ-Me— License No. Phone ~TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ }x s DESTRUCTION ❑ PUMP INSTALLATION F-1SYSTEMREPAIR ❑3V + - OTHER ❑ 3 DISTANCETO NEAREST::SEPTIC TANK ,- 'r"-SEWER LINES-- " " DISPOSAL FLD. -_ PROP: LINE 4 � .STFOUNDATION t AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ` PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial t ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia. of Well Casing (\ ❑ Domestic/Private ❑ Gravel Pack 'Cl Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ' C7 Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑$ Type of Pump j H.P. State Work Done Well Destruction ❑ , Well Diameter j Sealing Material (top 501) I Depth Filler Material (Below 501 t v ! TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION No septic system permitted if public sewer is available within 200 feet_1 Installation will serve:} Residence Commercial Other "f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: .6 t11 Water table depth 60 SEPTIC TANK i Type/Mfg � fr Capacity W-00 No. Compartments C9 L" PKG, TREATMENT PLT. ❑ L i i �� . Method of Disposal Distance to nearest: Well��O Foundation.Property Line__.. df LEACHING LINE 'E<' No Length Length of lines ar 70" 4t Total length/size r FILTER BED ❑ Distance to nearest: Weil 5 O_. Foundation [ Property Lirie ��Q k SEEPAGE PITS 4 ❑ Depth x10 Number SUMPS 11 Distance to nearest: WeIIZ�D ",Foundation �/ l Property Line 4 DISPOSAL PONDS ❑ 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: '9 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,1 shall employ persons subject to workman's compensa- tion laws of California." � f• r The applicant m st call for all requyed inspections. Complete drawing on reverse side. 'T Cr c Signed Title: T 0(AJ nDate: FOR DEPARTMENT USE ONLY Y3—?7- ,� Application Accepted by' DL�U_01f=� Date+ ` -3~uQ Area w Pit or Grout Inspection by Date Final Inspection by_ Date�� i Additional Comments: ❑ Stk 466-6781 El.Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Servioss 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'NO. INFO +EH 13-241REV.1/65) , 7y 70� a EH 14-28 "'1