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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. r / J Job Address y 3�✓� ' /H e/V N ��` City ST��J! TD!✓ Lot Size t/O y PM ,C Owner's Name c/O b lY r� ^ _Address 6 3� TAA/�� rrAn� Phone l u dars� BC W e �, fYf/89/ t`z3-//71 f Contractor yr/,f -6 Saiv (Address M f�t1 License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ ECL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 1 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ! PROBLEM AREA CON STRUCTION.;SPECIFICATIONS...._ �- -----:------ y ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack �11� ,❑ Tracy i4-+ Type of Casing 1 Specifications ['1 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout E 1 Irrigation _Approx. Depth- l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump ' H.P. State Work Done_ 6� Well Destruction ❑ Well Diameter r Sealing,Material {top 50'1 I Depth 1 Filler Material (Below 501 —! TYPE OF SEPTIC WORK: NEW INSTALLATIONJWI REPAIR(•A-DDITION-1-1--DESTRt1CTION l 1 (No septic system permitted if public sewer i available within 200 feet.) ; Installation will serve: Residence Commercial_ Other f'9aF`L Naw Number of living units: Number of bedrooms 3 Character of soil to a depth of 3 feet: C[. r `.-) 40f1M Water table depth I SEPTIC TANK ❑ Type/Mfg '05y. G.usT P'f _ Capacity-L3 0 No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal j Distance to nearest: Well Foundation a Property Line 49 LEACHING LINE Vr No. & Length of linesM}-x=-�'S� Total length/size d FILTER BEP ❑ Distance to nearest: Well e�� + Foundation .yl® Property Line yf� 1 + SEEPAGE PITS J/f Depth A✓� Sized Number i SUMPS ❑ Distance to nearest: � Well IJrd � f Foundation -A:e 94" Property Line DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, an rules and regulations of the San Joaquin Local Health District. I`�N j 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 I employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting"signature f 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 ccmpensa- tion laws of California." I i The applicant mut call for all required inspections" Complete drawing on reverse side. Signed X Title: I Date: I ' FOR DEPARTMENT USE ONLY 3A �j/) Application Accepted by1 Date r Area Pit or Grout Inspection by L Date Final Inspection Yv� 6/_ Dat Additional Comments: t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 {f� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 3/ FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT_NO�, I INFO I +-EH 13-24 1REV.I/x 511- EH 14-26