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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—MN AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED {Complete in Tripficatel 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 Loral health District. c`�r Job Address 4 r I • © ,5 7-riFly��_ w�.p Lot Size PM LJ Owner's Name , r +� Address � 1gk0 Phone 10 5 L66 � I ._ Contractor .Aiddress 3 - License No. _ .Phone_/ 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C3 PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE T FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ MantecaDia. 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 --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ID Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 5LfftPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence t/Commercial— Other Number of living units:-/— Number of bedrooms :3 Character of soil to a depth of 3 feet: S- D - Water table depth SEPTIC TANK &-"fype/Mfg Capacity-1-1 No. Compartments Q Pitt. TREATMENT PLT,❑ Method of Disposal w � Distance to nearest.' a Wall —,Foundation.Js-W Property Line�$DD LEACHING LINE r�ldo. & Length of linesTotal length/size— FILTER BED ❑ Distance to nearest: We+1` r l D• Foundation GkQn property Lkrte 5� SEEPAGE PITS ❑ Depth Size X10 Number SUMPSDistance to nearest: Well>�foundation r—Property Line / 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 laves,and rules and regulations of the San Joaquin'Local Health District. Home owner or licensed agen-t's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not f e y any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certif a following:"'I artily that in the performance of the work foi which this permit Is issued, I shall employ persons subject to workman's compensa- tion s laws California-" The applican st II for req 'ed in tin p drawing cit reverse skip. ZZ s;gr, rile: Date: —3 FO ARTMENT USE ONLY 1 i ,t�� Application Accepted y Date I Area V`�' Pit or Grout Ins I Y Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY PATE PERMIT'NO. INFO CAgTI +Et 13-24(REV,S 119 51 70 -0?( �d �'� ,w tri ,y, E114-2e