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APPLICATION FOR PERMIT { SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6761 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. TMs 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 Distract. .�[ //.}` Job Address __ (t Q n f CC/.i Y_ __-_ Citydl?SAS' Lot Size PM • Owner's Name .�(�.,C�C�/Lr.z;, 1,1��r',y Address -�ijtj f Phone 7•T y T /9 j Conliactor /-J'J!'•r c�� _Address • ,J C License No,f)gBSll'i� Phone ,1 r I TYPE OF WELL/PUMP: 1AW WELL ❑ O ELL REPLACEMENT I7 DESTRUCTION ❑ ..,,![ PUMP INSTALLATION ❑ SYSTEM REPAIR 11 OTHER 44 /`7o,V14- til Pe(r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (v-\ t,, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS jg4.ZWal 1"tJZ4,r LI Open Bottom Q Manteca Dia. of Well Excavation !q _ Dia. of Well Casing _' � I I Domestic/Private (I Gravel Pack ❑ Trac T pV L. Y Type of Casing Specifications _Z4 Y�!C�� 1 1 Public I-I Other (l Delta Depth of Grout Seal �,r7 Type of Grout A&A..r "PIZ4 - Inigatiun . ._ Approx. Depth I I Eastern Surface Seal Installed by %rs Y __ Repair Work. Done 1 Type of Pump H.P. State Work Done _ _ Well Destruction I I Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50'1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK LI Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 1.1 Method of Disposal t� Distance to nearest: Well _ Foundation Property Line LEACHING LINE I I No. & Length of lines Total length/size FILTER BED I I Distance to nearest: Well _ Foundation _ Property Line SEEPAGE PITS I I Depth _ Size __ ___ Number SUMPS I I Distance to nearest: Well _ _ Foundation Property Line DISPOSAL. PONDS I I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate 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 candy 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 must call for all required ins coons. Complete drawing on reverse side. Signed X_ �! � •w Title: 02'e-,&ti Date: 7� r� M "Ly Z Application Accepted by Date -J� -.�J Area Pit or Grout Inspecti b e3Yd' -- � 'S--31- Final Inspection by Additional Comment ' D Stir 466-6781 ❑ Lodi 369- 1 ❑ Manteca a23-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. HaZ6119P AV.. P. Box t CA of FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY GATE PERMIY NO. ERra.z.IREy.,, ER,x.26