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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT c3 1601 E. HAZEL T ON AVE., STOCKTON, CA E Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby made to the Sam 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 Addressr City `r4f.� Lot Size PM '" F Owner's Name J L� �d� " 1�i Address 74"Cf +n,f'•�/ �� f ,L ! � t Phone Con tIFactorALzwCrlr5� i �!!%ll�cidress 2a- 231-5License No. ";V C Phone X4 TYPE OF WELL/PUMP: J NEW WELL:❑ ELL REPLACEME ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM RE IR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLD. PROP. LINE _FOUNDATION AGRICULTURE EL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONS UCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom L7 Manteca Dia f ell Excavation Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack ❑Tracy T e of sing Specifications M Public n Other V F1 Delta epth of G ut Seal Type of Grout II I Irrigation _.Apprbx. Depth I 1 Eastern Surf.qce Seal nstalled by _ Repair Work Done E l Type of Pump H.P. State Work Done_ l Well Destruction ❑ Well Diameter S king Material Itop 50'1 Depth eller Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATIONNI RE AIR/ADDITION I 1 r'DESTRUCTION l I (No septic system permitted it public sewer is 1 { available within 200 feet.] Ipstallation will serve: Residence Commercial_ Other: ^ Number of living units: � Number of bedrooms ,_ Character of soil to a depth of 3 feet: _ �„fyT Water table depth SEPTIC TANK O ' T `� ype/MfgI� �� ` Capacity49ja&4 No. Compartments PKG. TREATMENT PLT. ❑ 1y f Method of Disposal n, Distance to nearest: Well ; Foundation Property Line LEACHING LINE ❑ No. & Length of lin,-4% Total length/size FILTER BED ❑ Distance to nearest: Well— _." Foundation 1 ocy Property Line SEEPAGE PITS 1 1. Depth_ Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 Lo 4, 1 health D1i1trict. Home owner or licensed agent's sign ture'cjgtifies 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 b ome subject to workman's compensation laws of California." Contractors 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 compansa- tion laws of California." II The applicant must call for all required inspections. Complete drawing on reverse side. X Signed Si S �rti t•ra-:n r A. f I _ _. g �� 1 +�; Title: �.W/�..�r�'.. c.. Date: !r� 96 FOR �EJpARTMENT USE ONLY Application Accepted by w}..y-w�, r pate Area Pit or Grout Inspection by Date Final Inspection by Date Z Additional Comments: alGrlf 171 Stk 466-6781 ❑ Lodi 369=3621 0 Manteca. 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE F AMOUNT DUE AMOUNT REMITTED ASR' RECEIVED BY DATE PERMIT'NO. E4 13.20,IaEV.1 r nsl '7 EK 1�•ZU r14-20,