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s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. °HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATEISSUED ,(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 Na. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address / . � �V r� r�a Q ity APT Lot Size 115--e-XI ice-- P1VI I 4 Owner's Name Address l�z phone { I Contractor dress t License No.��¢ :7 Phone TYPE OF WELL/PUMP: NEVVWELLI' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONSYSTEM REPAIR ❑ OTHER 1-1r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �� DISPOSAL FLD. PROP. LINE l� ; ' ~T FOUNDATION ` AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; ❑ Industrial i ❑ Open Bottom ❑ Manteca Dia. of Well Excavation / Dia. of Well Casing F Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' i'] Public j F] Other n Delta Depth of Grout Seal Type of Grout 77)AZ/ I I Irrigation Z2_90Approx. Depths®I 1 Eastern Surface Seal Installed byop y Repair Work Done Ll 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 Cl REPAIR/ADDITION i 1 DESTRUCTION I I (No septic system permitted if public sewer is j ` available within 200 feet.) a In'stalla'tion will serve: Residence_ Commercial_ Other E Nuri6er of liviAg units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t ` PKG. TREATMENT PLT. ❑ Method of Disposal I � j .� Y � i� hDistance to nearest: Well Foundation Property Line r l 'A LEACHING LINE 0 No. & Length of lines Total length/size , FILTER BED ❑ Distance to,•nearest:Well —Foundation Property Line rte^ P SEEPAGE PITS+;t� I I 'Depth:IY7 Size Number i SUMPS 6 DFC�tance to nearest: Well Foundation �s Property Line Q1 DISPOSAL PONDS E� C . .l =; I hereby certify that t 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. r r., 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 such manner a to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the,following: "I ceTtify-that�in he:performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws-df Califoinia.'1--1 I 3 y 3 The applican �Vr ewire Complete drawing on revers ide, t? 4 J r� Signed Title:. Date: 1/-7 1 _rIVIENT USE ONLY R E r� Application Accepted by rT` Date_ e�- "�;—Q� Area ` Pit or ro t Inspection by i -e f Final Inspection by Dat Additional Comments: ❑ Silk 466-67$1 ❑ Lodi .369-3621 f ❑ Manteca SM-7104 ❑ Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,_P.O..Box„2009,,Sik.,-CA-95201-- R A 95201..,, — INFO AMOUNT DUE FEE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. r y +.EH 13-24 1REV,I i M 5] 1 Q�r�T V� '�,�_!V �� _-13_3� ` EH 14-2e L u V - 1- 1 9r)—?0'4