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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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /� � Job Address ��/ rCIJ/C�f�" City �� Lot Size `z 100'19" PM Owner's Name C1 Address Ae/_ phone 3 v J / Contractor fie. /ce Address ��dc License No. �a3�21_ Phone - 6V 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 i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED'USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public # ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth t I Eastern Surface Seal Installed by _ Repair Work Done L7 Type of Pump H.P. State Work Done y„ � Vt Well Destruction ❑ Well Diameter Sealing Material (top 50'1 1A Depth Filler Material {Below ') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION DESTRUCTION I 1 INo septic system permitted it public sewer is i9 available within 200 feet.) Installation will serve: Residence J_ Commercial_ Other Number of living units: __V__ Number of beoms Character ofsoil to a depth of 3 feet: 140 —L04 4 rN Water table depth � r SEPTIC TANK ❑ Type/Mfg 66Z;C- 64C Capacity_A C6 No. Compartments ; Z- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well -761.�— Foundation `'�I Property Line LEACHING LINE L� No. 8 Length of lines F Total length/size _ FILTER BED ElDistance t nearest: Well Foundation o�S f Property Line 1 SEEPAGE PITS 11 Depth f' t Size V Number 2— SUMPS LlYDistance ton est: r Well_� ! Foundation r Property Line _._,— j DISPOSAL PONDS ❑ I hereby certify that I have prepared this application'and�hat the wo k_will-be."e in accorda'n'ce with iSan Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health,6il tact. ' } Home owner 6r 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 subiect,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 all requir d in ctions. Cotmplete drawls g on averse side. Signed Xlot Title: - �- --- -- Date: FOR'Dr t�ARTMENT USE ONLY�'� Application Accepted by Date S� Ar a or Grout 4nspection by r�_ ate Final Inspection by °� Date R Additional Comments: ❑ Stk 466=6781 6-" o'di7:-- 621—F-yMantYf6--823--7104 O'Tra+:y 635'6385 — Applicant - Return all copies to: Environmental Health Permit/ServicasN601 E. kazelion Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. t,EH1 3-24 iREV.1/H 51 O �� L 2 EH 14-26 -�Z- Q