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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-67$1 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ., y (Complete in Triplicate) >v, Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Thos 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 3 q . r V Cit Lot Size t � PI41 Owner's Name 110,4 r Address 12 (/31 r /V• GZL;[a 7r Phone D I — / Y I Contract at Address y l�. '��&) .License No. W-2 Phone G '��a� TYPE OF WELL/PUMP:, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES'-- DISPOSAL FLD. PROP, LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---�-Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 j Depth Filler Material (Below 501 '. TYPE OF SEPTIC WORK: NEW INSTALLATION EPAI ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is ' available within 200 feet.] W i Installation will serve: Residence_ Commercial—� —Other • `f Number of living units: ' Number of rooms 13R vw" � Character of soil to a depth of 3 feet: Water table depth ,vo SEPTIC TANK ❑ Type/Mf" - - - - 11" Capaciiy, l1'O rNo. Compartments a �" PKG. TREATMENT PLT. ❑ ---,-_,Method of Disposal Distance to nearest: Well :20 Foundation_/ 4 -Property-Line �S LEACHING LINE - No- & Length of lines L G Total length/size a.rvZ Y o� FILTER BED Distance to nearest: Well Qr Foundation_�� ' f• Property Line �'" _ _ �1/ SEEPAGE FITS Depth AS Size ,3.3/ I Number' FO�� SUMPS 0—Distance to nearest: Well Foundation 1) Pro :"f' �� /�..�. �rty.L•ine S DISPOSAL PONDS �I t- _ f 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&workman's Compensation-laws of Calif6(nia:"Contractor's-NNF 6 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'slcompensa- tion laws of California." t i The applicant st call for eq u'ed inspections. Complete drawing on reverse si e. Signed i Title: Date: r / E FOR DEPARTMENT USE ONLY Application Accepted by Date V Area }. Oit rGrout Inspection by ate Final Inspection by --IDate 7 ' ! /df Additional Comments: FYT ❑ Stk 466-6781 O Lodi' 369-3621 ❑ Manteca 823-7104 ❑ Tracy" 835-6365 a Applicant- Return all copies to:: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2005, Stk., CA 95201 i INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH 13-24 SREV.'v R 51 EH 14-28 I Q I�� L