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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601-E. HAZELTON 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.r549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. t Job Address 0 13 1 h)OD- F, 14W V 'A2 City Lot Size 40 at/424) PM Owner's Name 1rJ V��n1 /7�` n Address Q v Phone 3 o 3� Contract k Address PQ. ~7 C' License No.3 �Z�- -Phone TYPE OF WELL/PUMP: NEW WELL ❑„T,,-CC�LWELL REPLACEMENT-❑. DESTRUCTION ❑ PUMP INSTALLATION-,❑---- -x- -SYSTEM REPAIR ❑ 1 OTHER 0 DISTANCE TO NEAREST-,SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION/, AGRICULTURE WELL OTHER WELL PITS/SUMPS r.. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open`'Bottom, ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑.G'avel,Pack ❑-Tracy"�� Type-of Casing Specifications _ f 1-1 Public c � ❑-Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern- Surtace Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done . Well Destruction ❑ Well Diameter -Sealing Material{top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 9K REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) i '`Installation will serve:_Residence Commercial— Other '-N tuber of living units: !Number of bdraoms Character of sail to a depth of 3 feet: --t-8 - —Water table depth `J SEPTIC TANK 4 Type/Mfg C&AeC, Z Mono No. Compartments PKG. TREATMENT PLT" ❑ r r Method of Disposal Distance to nearest: well -5'6 Foundation 10 Property Line s r LEACHING LINE Z]/No. & Length of lines Total length/size r r , FILTER BED LJ Distance to nearest: Well � Foundation--/o Property Line SEEPAGE PITS K Depth _Size Number 3� f SUMPS LJDistance to nearest: Well Foundation /4 r Property LL'1n'e DISPOSAL PONDS ❑ 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. Home owner or licensed agent's signature certifies the following: '9 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 rrust call for Are ired inspections. Complete drawing on reversee. Q Signed Title: �2 V Date: FOR DEPARTMENT USE ONLY 'Application Accepted by _- .---- - - Date 4J ,Area Pit or Grout Inspection by Date Final Inspection by Data s 2 r Additional"Comments:- - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY /DATE PERMIT'ND. /,IREV.1/851 Q - ''' "7i/D (O J%NAtil.