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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I i (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 "7__J_ L' Jr�r�7v[ D x�C 1 !�( _ City Cl/ Lot Size PM r 1 Owner's Name Address !:9� S .�73J/-Z-.1,MCs Phone Contractor Ally-i t�111_L AddressA� License No. Phone a TYPE OF WELL/PUMP: , NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 LSrECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well'Excaiiation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - Specifications ' M Public Ll Other ra Delta Depth of Grout Seal Type of Grout r § I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 N Depth Filler Material (Below 50.1 _ { TYPE OF SEPTIC WORK: NEW INSTALLATION f'I REPAIRlADDITION DESTRUCTION I ] INo septic system permitted if public sewer is `-tom ! available within 200 feet.I Installation.will serve: Residence Commercial_ Other Number of living units: Number of-bedrooms 7��_ _' Character of soil to a depth of 3 feet:,L' ,-- &"' o 0��"�' � *" P � _ Water table depth SEPTIC TANK ❑ -Type/.Mfg Capacity f No. Compartments x PKG. TREATMENTPLT 0 �� _ Method of Disposal Distance to nearest: Well """""'Foundation. Property Line LEACHING LINE No&~Length of-lines _ �Cl� —� _ Total length/size FILTFER BED ❑� Distance to nearest: Well Foundatiori� F_'z Property Line r SEEPAGE PITS 11 Depth Size ' Number r SUMPS Ll Distance to nearest: Well Foundation dry- w. Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance witFi San Joaquin county ordinances, state laws, and rules and regulations of the San`Joaquin Local Health District. , '111 ¢ 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 4 employ any person in such manner as to become subject to workman's compensation laws of-California." Contractor's hiring or sub-contracting signature t certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ poisons subject to workman's compensa- tion laws of California." The applicant must call for re fired inspections. Complete drawing on reverse side. ry Signed X Title:._ Date: mar/d FOR DEPARTMENT USE-ONLY 69� Application Accepted by _Date _!2'.12 4 Area �b Pit or Grout Inspection by Date Final Inspection by Date 0 Additional Comments: l .- " b Stk 466-6781 ❑ Lodi 369-3621 ❑ Msntece 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 r ,.•t _ ..� . .-r. t -. - we.y�y�T.- .. ..x. - .. - _. ww.r-..+r.. '=�+r�. — --.yu...��i.s,+er -_ —. —��. -'�.'ieu'.w.iM�.YIeF.-'r..zr.--.�..r,rw• - 4. FEE INFO OUNT DUE AMOUNT REMITTED CASH X RECEIVED BY DATE PERMIT'.NO. r i +.EH 13-24(REV.'l 5Y '3y} F EH 1426 G.O Q '01- —n7,D -i V 53 i