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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 _Oi(1 City 4e/7/ Lot Size /�aC 04� PM 0/0 Owner's Name A)' 0'L-• SL,4/121144 '9 Wo—Address !/ Phone — 3 Contractor �Ld�� E. �t90� Address 7 AA Xb44/ _�,e7— AUS License No. �aisY7G Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 Fl Public 17 Other - ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —_ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ 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 I 1 REPAIR/ADDITION)() DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: ! Number of bedrooms '2-- Character Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 7-141-Z- Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE C9'-No. & Length of lines 440 Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation .S G Property Line i O SEEPAGE PITS Depth Z Size 3 3Number l/ � SUMPS ❑ Distance to nearest: Well AM Foundation //Q , Property Line ,S n 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 laws, and rules and regulations of the San Joaquin Local Health Diltrict. 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 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, t shall employ parsons subject to workman's compensa- tion laws of California." b The applicant must call for all required inspections. Complete drawing on reverse side. b Signed X_ � al Title: Date: -:T-- 7•— 91 { 1 FOR DEPAR ENT USE Y Application Accepted by M . para ��, �Area�/ 1 Pit or Grout inspection by bate Final Inspection by �v v Date L Additional Comments: ` ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy '83t-6385 Applicant- Return all copies to: Environments Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 95201 IEEE OUNT DUE AM NT EMITTED I CASH REMVED BY DATE PERMIT-NO. . ENI 3-24 tiiH51 [l r� L f�J �J 10 4-2e glJ�liJO EH 1 �' l