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APPLICATION FOR PERMIT ' ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 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. i Job Address �°Z 57— � City Go bf Lot Size AGE PM i Owner's Name DA010Zp/414`C:A "/V aR dress �aeFS_..VV-- � a[-. �d 'r4C.4 Phone 7-4-dgT Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELLZ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO !NEAREST: SEPTIC-TANK /QUI � SEWER LINES f/'� A DISPOSAL FLD. 1"' PROP. LINE "O ! 'a FOUNDATION 7AGRICULTURE 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 fieoomestic/Private 54 Gravel Pack ❑ Tracy Type of Casing Specifications M Public n Other F.7 Delta Depth of Grout Seal 50 Type of Grout__- I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 17 Type of Pump 1 ' H.P. 1'/1 SIA, s w State Work Done Well Destruction ❑ Well Diameter ,r __ Sealing Material (top 501 Depth Filler Material Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION FIEPAIR/ADDITION ( I DESTRUCTION i I (No septic system permitted if public sewer is C1_ j available within 200 feet) —1l Installation will serve: Residence; Commercial"t Other Number of living units: ( Number of bedrooms Character of soil to a depth of 3 feet: 5'4 AV A C/4 F-1T cEM�•cJf' ,ree �� Water mpaable depth SEPTIC TANK Type/Mf ZB �apaciey �'ZaO e'er/ No. Compartments � PKG. TREATMENT PLT. L16� Method of Disposal Distance to nearest: Well / Foundation �0 r Property Line 3 S �- LEACHING LINE ❑ No. & Length of lines Total length/size �— FILTER BED ❑ Distance to nearest: Well Property Line SEEPAGE PITS X Depth J S� ' Size g� y/,4 Number Z_ r SUMPS ❑ Distance to nearest: Well //Z Foundation /�„�_ Properly Line 3� DISPOSAL PONDS ❑ i Y 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, an 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 parson 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 must call for all required inspections. Complete drawing on reverse side. Y Signed X Title: Date: a FOR DEPARTMENT USE ONLY Application Accepted by Date Area G 7�z -f O Pit or Grout Inspection Date { J Final Inspection by Dat ^^11 r Additional Comments: V�/ v �./U Y d [awl Ov+r v r' w � ❑ 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 95201FEE �� • '! �f I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM`T'NO. '�14-2giREV.1in51 —730 `00 �4 r'r 7'��U� • ��7