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r APPLtOATION FOR-PERMIT,. SAN JOAQUIN LOCACHEALTH DISTRICT,, 1601 E. HAZEL T ON AVE., STOCKTON, CA Telepli&e'.{209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED'" et' "il :•- �,. s f Complete in Triplicate}" TM s'_ 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 j made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. s -W! . ` ?: ..�1 . Job Add `ress " r�/ } l i Cr#Y .. r. Lot Size � �WPM f Owners Name ' =7 Address -- Phone - FF ,� �sd 1 <W Contractor t- i ILTZ1cA L Address License No. Phone —TYPE-OF-WELL/PUMP:'"'"�`"""`—"NEW WELL❑—WECL'REPL4'CEMENT'❑'— " %-DESTRUCTION'❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —INTENDED-USE.. TYPE.OF-WELL--i-PROBLEM-AREA— GONSTRUGTION-SPECIFICATIONS • - .•. .».- •❑ Industrial ❑ Open,Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing ❑ Domestic Private ❑ Gravel Pack ❑ Tracy Type of Casing ' Specifications �❑ Public ❑ Othery ❑ Delta Depth of Grout Seal I Type of Grout E❑ Irrigation __-,__Approx. Depth ❑ Eastern_ Surface Seal Installed by j Repair Work Done ❑ Type of Pump H.P State Work Done t ,Well Destruction ❑ Well Diameter = Sealing Material [top 501 € �' Depth 1 Filler Material /Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION & r EPAIR/ADDITION ❑ .DESTRUCTION ❑ (No septic system permitted if public sewer is "_ available within 200 feet.) # Installation will serve: Residence t�Comercial Other_____j Number of living units: . Number of bedrooms _ Character of soil to a depth of 3 feet � 1 Water table depth SEPTIC TANK C�Type/Mfg � Capacity—LAD—a— No. Compartments _13— 'PKG. TREATMENT PLT. ❑ } Method of Disposal Distance to nearest: Well Foundation Foundation Property.Line __ LEACHING/Ii +' .' L 'o:& Length of lines n =- - — Tota! length/size"' { \\ 1 FILTER BED ❑ Distance to nearest: Well. c s Foundation Property,Line :75 t SEEPAGE PITS /Depth size Number I SUMPS ❑ Distance to nearest: Well Foundation Property Line ` y -� DISPOSAL PONDS ❑ E l � p hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and -rt rules and regulations of the San Joaquin Local Health District. i Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permiIfis 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 I of California." ` The applic ust call for alll req i ed in ctio plea drawingDate: 7� on reverse sid d Signe I i itle: , 3 1•� -FOR DEPARTMENT USE ONLY s Y Application Accepted by "- bat Area -Pit or Grout Inspection by ate a 5 Final lrisp'ection by Die , Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Heal#h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 T FEE ; AMOUNT DUE AMOUNT REMITTED , # RECEIVED BY DATE AERMIT'NO. INFO .EH 1426 11 � -.�...: 3 p � - �..� ��--- ,....� ••