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If 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. : .�, Al Job Address _.2 2 [� �"- A)" 1Z � City t of Size PM Y r Owner's Name 1..> _7 } ateJ F�_Address 84!_o-(( wl"".ne q%-381_1&40 Contractor's Name r� ��&TA—fticense No. 4o23_:::) Phone v^ { a a TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` N PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ " OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ 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 ❑ Irrigation _.Xpprox. Depth ❑ Eastern Surface Seal Installed by v Repair Work Done ❑ Type of Pump H.P. - State Work bone Well Destruction E3Well Diameter Sealing Material (top'50') �j f 4 Depth Filler Material (Below 501 ISI TYPE OF SEPTIC WORK: NEW INSTALLATION PC REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: lisY. Water table depth T J L SEPTIC TANK Type/Mfg - SM4 C-4t'G�6. Capacity__ No. Compartments �� I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: , Well `"` Foundation Property Line + �-� LEACHING LINE No. & Length of lines JTotal length/size exin FILTER BED ❑ Distance to nearest: -Well Foundation #/O Property Line fs SEEPAGE PITS v Depths i Size I Number SUMPS ❑ Distance to nearest:' Well Foundation + 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 laws,and 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 for which this permit is issued, I shall not employ any person in suchmanner as become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following:"I certify the t e performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." S The applicant must call r equi inspections. Complete drawing"on reverse r, _� � " Signed Title: 't Date: C:)-T- FOR DEPARTMENT USE ONLY �� s Application Accepted by Dat Area 62, Pit or Grout Inspection by yDate Final Inspection by DateV '%.,/ w Additional Comments: , "(' r, Z x �tk 466-6781.., • _,❑ Lodi ,369-3621 Manteca 823-7104 ❑,Tracy 835-6365 _ — Applicant- Return all copies to:,Environmental Health P rmit/Services 1601 E. Hazelton Ave., P.O.`Bpx 2009, Stk., CA 95201�FEE INFO 'T "AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT"NO. +EH 13-24(Red.101831 d, EH 14-26