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APPLICATION FOR PERMIT SCA r ED SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. G // C Job Address 1105L-6 . . City S7Z7 C_k_1_0N Lot Size 2C3fJ PM Owner's Name �AM+�S �'a, 4 Address 4/9-P-`74 Phone 6 —76cc,4- Contractor's Name Sf+'l494-- License No. Phone w,6—%0 TYPE OF,WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 6 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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. {7 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout (� It Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 'I Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 "(5 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION W DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) g. Installation will serve: Residence-,V_ Commercial_ Other Q Number of living units:?e Number of bedrooms Character of soil to a depth of 3 feet: I)_D®84G Water table depth S SEPTIC TANK Pr Type/Mfg CE?nOG�r=,?�— �S Capacity 1.2-00 No. Compartments Z' PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation R_ Property Line 30 LEACHING LINE 19 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 620' Foundation �_ Property Line A0 SEEPAGE PITS ;X Depth 426 SUMPS ❑ Distance to nearest: Well LVD Foundation 60 Property Line /D 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 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 folio ing:"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 Cali rnia.' The applicant I for require spe�ns. C, ete drawing on. reverse side. a Signed Title: ` ( —>!�-� Date: 2 7— � R EP ENT USE ONLY Application Accepted b Date — A a l�- Pit or Grout Inspec n byDate `O Final Inspection by Date Additional Comme ❑ Stk 466-6781 ❑ Lodi 3W4621 ❑ Mdnteca 823-7104 ❑ Tr y 5 Oi// -Ze-, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, k., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK ASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.10/831 S' /( � a EH 14-26 ��