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r - !' 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) a 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 r-� Local Health District. Job Address z SyI3 So, aieyrA — City rY�Y _ Lot Size PM Owner's Name It Avr v Address :2/,?/ A%love Phone i^ Contractor A *,V Address #0. JZ r 610 `It>Qf"O 111 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ d .• PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANGF�NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE DATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Y INTENDED USE TYPE OF WELL, OBLEM AREA CONSTRUCTION SPECIFICATIONS (Al ❑ Industrial ❑ Open Bottom ❑ Mant Dia. of Well Excavation Dia. of Well Casing . ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o Specifications b C7 Public ❑ Other Cl Delta Depth of Grout Seat Type of Grout ❑ Irrigation Approx. Depth U1 Eastern Surface Seal Installed by ` Repair Work Done ❑ Type of Pump H.P. State Work Done ! Well Destruction ❑ Well Diameter Sealing Material {top 50'1 Depth Fillei Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/AaDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is _ available within 200 feet.) Installation will serve: Residence ` Commercial_ Other R Number of living units: _� Number of:bedrooms - Character of soil to a depth of 3 feet: &44' A AI Water table depth SEPTIC TANK ❑ Type/Mfg e0&;X<'T& PYQ C-A--7 ._ Capacity %Z6c— No. Compartments A. PKG. TREATMENT PLT. 171 Method of Disposal ` Distance to nearest: Well .3v 41r Foundation /e If Property Line /Yo r- LEACHING LINE Na. & Length of lines QC s Total lengthIsize !gw . - � - FILTER BED ❑ Distance to nearest: Well °e' Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ P 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."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." The applicant must call foriall required inspections. Complete drawing on reverse side. Signed Title: Date: 'r- - 30 R DEPARTMENT USE ONLY �J Application Accepted!by _r Date13 / Area Pit or Grout Inspection by ,` Date Final Inspection by Date ;f Additional Comments: _ 417-A 'a ❑ Stk 466.6781 ❑ Lodi 369- 1 ❑ 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 I AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. INFO CASH 7 +EH 13-21[REV.t/65] s/ �(! EH 11-28