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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'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 F Local Health District. � � Job Address W I `�LZ A �!`"rt Cit Lot Size PM Owner's Nam Address � •qi Phone Cantracio 'r4 f {; Address . License No, 9 �Cf ' Phone30 "5_105_Z9 TYPE OF WELL/PUMP:' +' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ s 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 t O ❑ Industrial f ❑ Open.Bottom 'O,Manteca Dia- of Well Excavation Dia. of Well Casing Ll Domestic/Private = ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"1 Public l I l Other l ❑ Delta c Depth of Grout Seal Type of Grout I i Irrigation �T�Ap rox.-Depth._ I I Ea'ste'rn Surface Seal Installed by Repair Work Done •❑ Type of Pump "'"��yH P, — State Work Done_ Well Destruction L1 Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.► Installation will serve: Residence Commercial r " Other Number of living units: 3 Number of •� 1 Character of soil to a depth of 3 feet: I �/' ,.,� Water table depth ' SEPTIC TANK D/ Type/Mfg' ' Capacity.-.(_LCOO — No. Compartments PKG. TREATMENT PLT. ❑ f /� i Method of Disposal Distanc`e`to-nearest: W -_-__ Foundation—t rl .-- Property Line I f � A. LEACHING LINE No. & Length of lines Total length/size U K FILTER BED- ' _. ❑ Distance to nearest: Well_ d� Foundation 140tProperty Line SEEPAGE PITS Depth Size r Number r SUMPS 3 Ll Distance to nearest: Well./;jam Foundation_-. {o Property Line DISPOSAL PONDS ❑ f4 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. I . 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 parsons subject to workman's compensa- tion laws of California." k � The applicant m call for a!I re ire inspections. Complete drawing on raver si Signed Title: `� .. - _ . �J D[tea' U Date: ' '--- �FOR,f]EPA'RTMENT'l'!SE-FOR - Application Accepted by �� Date r 2 3-,:9r—/ Area C/ Grout Inspection by Date �u Final Inspection byr Da� Additional Comments: f i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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[ K 4 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'No. t + EH 13-24 MEV.i/H 5) EH 14-26 �3 �5 ti-