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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. Job Address 4$lb s� cz&c1AfTT/' AAWAC City 4O Lot Size �� k, )Stat PM _ got ;2 ,8 U N+ V Ic L.O.9 Owner's Name YG�/V u T Address v�WO L[,c%�i�T� �� Phone %46,1n97_6_ Contractor's Name &I--T- License No. 33Z-- /07 7 Phone V-7Zs T TYPE OF WELL/PUMP: 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 ❑ Domestic/Private ❑ Gravel Pack. ❑.Tracy _ � Type of Casing Specifications ❑ Public ❑ Other ., r ❑r Delta Depth of Grout Seal Type of Grout 17 Irrigation Approx.Depth' ❑ Eastern Surface Seal Installed by y Repair Work Done ❑ Type of Pump - H.P.. State Work Done Well Destruction ❑ Well Diameter ,.Sealing Mateiial (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION OK REPAIR/ADDITION ❑ DESTRUCTION No septic system permitted if public sewer is Q available within 2 � + p b0c Installation will serve: Residence_ Commercial��Other � ,.� 1��1 014� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 122639 C446e Water table depth '30'6' '76" SEPTIC TANK 0„1-1 X Type/Mfg C4Capacity /ZOO No. Compartments Z PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 175 Foundation .I'V Property Line 17 LEACHING LINE No. & Length of lines -73 1'' Total length/size /ZS FILTER BED ❑ Distance to nearest: Ws1I foundation Property Line SEEPAGE PITS epth _... Sizefli Number—01- SUMPS ❑ Distance to nearest: Well Foundation Property Line 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: "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 m call for all r uired inspect. ns. Complete drawing on r arse side. Signed f Title: i� Date: �_`G—�� Aelix [ FOR DEPARTMENT USE ONLYt d Application Accepted by Date'4. ` Area v Pit or Grout Inspection by DateFinal Inspection by I Additional Comments: . .. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 8355-638.5 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 CASH RECEIVED BY DATE PERMIT'NO. +EH13-24(REV.11018M 2--12,-g°s 8s-jY97 EH 1426