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_ k 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 rmade 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 A Local Health District. Job Address 30 3,Fe750, TY,4C K I/C7" —..City �Cy_---- Lot Size PM ^—=Owner's•Name---.�-/�eriC!_-1/j!.,1_��,f%�Address—.�d._3-J�O—.SO_. C, ��L;�.. �3�O �l�d— -i �r Contractor �""�� '8'Y f Sc Address 6� r�"r~' y� License No. yyy�g9� Phone TYPE OF WI=LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO-NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE e FOUNDATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED.USE..,.: TYPE.OF WELL ,.,,_PROBLEM AREA CONST(.UCTION SPECIFICATIONS Y ❑ Industrial v 0 Open Bottom. _. ❑ Manteca,- Dia..of Well-Excavation Dia. of Well Casing 6 ❑ Domestic/Private ❑ Gravel Pack i=*• .❑ Tracy Type of Casing Specifications M Public ❑ Other Cl Delta Depth of Grout Seat Type of Grout i I Irrigation' _..Approx. Depth I I Eastern Surface Seal Installed by Repair Work D"one x❑ Type of Pump H.P. State Work Done_ r Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 50 _ 4 TYPE OF SEPTIC WORK: NEW INSTALLATION Vf REPAIR/ADDITION l I DESTRUCTION t I (No septic system permitted it public sewer is 4 available within 200 feet.) Installation will serve: Residence— Commercial L Other ' I Number of living units: Number of bedrooms f?j Character of soil to a depth of 3 feet: S��rr�Ir &7-19"e f- Water table depth SEPTIC TANK 171Type/Mfg �°Y� C& s 7' Capacity y��all No. Compartments � PKG. TREATMENT PLT. ❑ f • r Method of Disposal Distance to nearest: Well Foundation t Property Line CSO LEACHING LINE s r& Sed._. Total length/size 00' 130 FILTER BEDDistance to nearest: Well Foundation /r4 Property Line /S I SEEPAGE PITS t I Depth Size k{ - Number V:1 ' SUMPS i._1 Distance to nearest: Well Fou6tlation4 Property Line DISPOSAL PONDS ❑ w 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. t 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."Contractors 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." f The applicantZIN all for all required inspections. Complete drawing on reverse side. Signed X i Title: ~ ' - `t Date: " Z 01 ig 9 �kQR DEPARTMENT USE ONLY K t Application Accepted by Date Area Pit or Grout Inspection by Date-- -— Final-Inspection by- Date 7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. ♦ EH 13-24(REV.1/a5) �� S-S^]' l