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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT h 1601 E. HAZEL T ON 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 Addre ,��W STaZM+9�v� City Lot Size PM I e Owner's Name 6944.,e Pa141L sG-- Address, Phone A r ` Contractor's Name License No. �2 Phone V,3 ef �3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR E3 OTHER El DISTANCE-TO NEAREST: SEPTIC TANK E SEINER LI S _{ DISPOSAL FLD. PROP. LINE j FOUNDATION, AGRICULTURE WELL . OTHER WELL PITS/SUMPS INTENDED USE TYPE OF -_ELL':- 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 - C] Delta Depth of Grout Seal Type of Grout ❑'Irrigation --Approx. Depth;' ❑ Eastern) Surface Seal Installed by Repair Work Done ElType of Pump H.P. i State Work Dane M Well Destruction ❑ Well Diameter Sealing!,Material (top 501 u" • Depth '' � — ',Filler Material (Below 50') ' TYPE OF SEPTIC WORK: _.NEW INSTALLATION ❑ REPAIR/ADDITION ❑- DESTRUCTION ❑ (No septic system permitted if public sewer is available:within-200-feet.i Installation will serve: Residence v Commercial_ ''Other v' ?Number of living units:_-(— Number of bedrooms Character of soil to a depth of 3 feet: 4 D,13 1.4- " Water table depth SEPTIC TANK 1§f Type/Mfg Capacity ,/�"' No; Compartments a II PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line ,'a"�► ► 107— Distance T } v LEACHING LINE No. & Length of lines V Dotal length/siz7— f� FILTER BED ❑ Distance to nearest: Well Foundation Property LineZp F4— 1 ti +SEEPAGE PITS ❑ Depth - Size /40'.X * / Number t SUMPS Distance to nearest: — Well }� Foundation Property Line 'DISPOSAL PONDS ❑ I hereby certify that l have prepared this application and that'Che work will be done in accordance with San Jqaquin 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 must call f r all required inspections. Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Srl Area � Pit or Grout Inspection by. Date `' —--Final Inspection byr�' C� �' ate 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.0 Box 2009,.Stk4 CA 95201 FEE -AMOUNT DUE-" AMOUNTREMITTEDCK#" RECEIVED BY DATE PERMIT'NO. j' INFO CASH +EH1324(REV.10,83I � �V Il/'�f�{•) —��-{O1 Z 1176