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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT + 1601 E. HAZETON AVE., STOCKTON, CA r 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 1-746 ��MiVF D' Z CityU��1 Lot Size 4& x 1 a PM I //l44�L T. �- Owner's Name 7-Address �� 2^�5$`8 Phone Contractor's NameP,4P12e5lV License No. 5 phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ElOTHER 171DISTANCE TO NEAREST: SEPTIC TANK .0 SEWER,LINES DISPOSAL FLD. PROP, LINE _;°" ;f-�FOUNDATION 1 AGRICULTURE WELL >OTHER WELL PITS/SUMPS INTENDEf7,US.E'. �f t-TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS �, O Industrial. -, �, ❑,Open-Bottom A EI Manteca Dia. of Well Excavation t , .. Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack "�❑-Tracy ^Type'of Casing Specifications {" ❑ .Public :p OtFier ❑ Delta Depth of Grout Seal_ _ Type of Grout - ti k. ❑ Irrigation --Approx. Depth .0 Eastern Surface Seal Installed by '- r Repair Work Done ❑ ' Type of Pump: 12_1 1 � H.P. State Work Done Well Destruction ❑ Well Diameter —Si ailing Material (top 50') f Q Depth Filler, eteriaj.'lBelo.50'1 I d TYPE OFSEPTICWORK: NEW INSTALLATION❑ REPAIR7ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer '5_ i available within 200 feet.) i ! Installation will serve: Residence Commercial— Other j ! f /y Number of living units: Number of bedrooms — #.'� V F Character of soil to a depth of 3 feet: Water table depth t- SEPTIC TANK W Type/Mfg S Capacity_ /Z Z>4!2 No. Compartments a Y PKG, TREATMENT PLT. ❑ [ _ Method of Disposal 1 r p Distance to nearest: Well -Foundation Property Lirie S� r� 1. ri LEACHING LINE & Len th of lines gTotal length/size y FILTER BED ❑ Distance to neaFes't:•_ Well Foundation Property Line SEEPAGE PITS 1] Depth Size Number, SUMPS ❑ Distance tolnearest: Well Foundation Property Line DISPOSAL PONDS ❑ I w: 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: 1 certify-that-in-the-performance-ofthework-for which this permit is ised, 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 follawi :"I certify that in the perfor ante of work for which.thi rmit-is-issued, I shall employ persons subject to workman's compensa- tion laws of Calif is. The applicant t c for all re 'ed inspe ns. mplete drawing r re a side. ` Signed Title: Date: i 1{ FOR DEPARTMENT USE ONLY ' Application Accepted by Date Area= � Pit or-Grout-inspection-by - 1— ._Date-- Final-Inspection- — .° y pie Additional Comments: ❑ 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 - INFO FEE AMOUNT DUE AMOUNT REMITTED CK#CASH RECEIVED BY DATE PERMIT Np. y + EH 13.24IREV.10/831 /6� Li 4+t� EH 1428 6 -