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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) i Application isistrict.teby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is mLocal Health Disade 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" I ' Job Address r 'st7 Sb• T), 4 c, City r2o'/ti+ C Lot Size PM Owner's Name SO4 y pa 15vs67— MS Address Phone I .,...,,..,,_„Contractor. �%iv �' SDS Address .t ' TYPE OF WELL/PUMP; License No. 5�f� -8',�/ phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ `PUMP'INSTALLATION'❑ " " SYSTEM REPAIR'.❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION .AGRICULTURE WELL OTHER WELL «-- PITS/SUMPS _ INTENDED USE V TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial CI-Open Bottom ❑ Manteca •" " � " rt_: D+a. of Well Excavation _" Dia. of Well Casing I ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy T I ❑ Public Type of Casing Specifications f_] Other 1-1 Delta Depth of Grout Seal I I Irrigation � A J �TYPe of Grout—_ pprDepth ' I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H P s Well Destruction ID Well Diameter State Work Done Sealing Material {top 50') J Depth, J - Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION f REPAIRlADDITION f 1 DESTRUCTION ! I (No septic system permitted it public sewrer is Installation will serve: Residence ° , ' . available within 200 feet ) 0 ' Commercial_ Other "'01'a /-,f ; Q�/C S Number of living units: Number of bedrooms ._ Character of soil to a depth of 3 feet: `. Water table depth SEPTIC TANK ' Capacity A YOD ❑ Type/Mfg /fir G��T p y PKG. TREATMENT PLT. LINo. Compartments Distance to nearest: Well i'mss -. _ pertMethod ofy Line bi0Osposal "^` itA Foundation Pro ' LEACHING UNE 1 No. & Length of lines 6 --7 947' yD FILTER BED ' Total length/size M❑ Distance to nearest: Well '1-210 ' "Foundation Vel' Property Line—10 —_ SEEPAGE PITS I I Depth * Size Number SUMPS , ❑ Distance to'nearest: Well Foundation DISPOSAL PONDS ❑ Property Line 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 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 laws of California." The applicant mu call for all required inspections. Complete drawing on reverse side. Signed Title: Data. 7".A Er FOR DE ARTMENT USE ONLY Application Accepted by Date 3 Area Pit or Grout inspection by .01 Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 1 ❑ Manteca 923-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE 3 AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. + EH 13-24{REV,i i q 51 EH 14-28 `` --`` B9—125