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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ; Telephone (209) 468=6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made{o the San Joaquin Local Health District fora 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 t Local Health District. 3 t i Job Address f `7 7� City LfAl,D Lot Size PM Owner's Name j-..�JL1 DG—/1� :ASSC1C'. rrfa�ddress Phone - e Contractor _P4 ,06C• woo.D Address Sri' License No.0_74rY74 Phonela C-3-`'71 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT.E]DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIRr❑ 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 SPECIFICATIONS C7 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications- * Public F1 Other CI Delta jDepth of Grout Seal Type of Grout I I Irrigation _--Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done LlType of Pump H.P. State-Work Done_ ` Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth ,Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet./ Installation will serve:' Residence Commercial r Other J, Number of living units: __/_ Number of bedrooms - 3 r ' Character of soil to a depth.of 3'feet: e Li_A !I.- 777t4'Water table depth SEPTIC TANK L3thTypelMfg L'G1 - l490,t- Capacity �_�� s No. Compartments PKG. TREATMENT PLT. ❑ ._� `,_ _ .W Method of Disposal Distance to nearest: Well—/S'd Foundation Property Line LEACHING LINE Cly No. & Length of lines —' 85` _ _. T.otal.length/size `X Z FILTER BED ❑ Distance to nearest: Well_Z 6Q_ .. Foundation K)49. ___- Property Line - r SEEPAGE PITS (""Depth .�_�'_ _� Size e' Number - SUMPS ❑ Distance to nearest: Well � A50 Foundation was Property Line 'AWS ! 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 k 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'f6r 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 for all required inspections. Complete drawing on reverse side. n /p Signed X �t�� LG1IJ tl�! _ Title: (�e- Date: ��GG FOR DEPARTMENT USE ONLY 4 +_ , l Application Accepted by ""'�Y Date `©- tS .001 Area �,� Pit or Grout Inspection b Date TFinal Inspectio by Date f fJ �� Additional Comments: © Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trac 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED C T RECEIVED BY DATE PERMIN0. ._EH-14.28(REV.5 1 H 51 e� �� 1��j.'