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APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT • 1601 E. HAZELTON AVE., STOCKTON, CA >' Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED ICornplete 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. t ,(_ Job Address�_lPD' 5-4,"•I Eyy City __. -T Lot Size 7,545— PM Owner's Name I r=��V � .t7 Address 14,&(4 Phone 19 r&12- Contractor Address - License No. Phone TYPE OF WELL/P P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 Cl Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public ❑Other ❑ Delta Depth of Grout Seal Type of Grout_ I I Irrigation —.Approx. OeMh ( I Eastern Surface Seal Installed by - \ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is j • available within 200 feet.) Installation will serve: Residence v Commercial_+� Other �i Number of living units: _*j Number of bedrooms r Character of soil to a depth of 3 feet: CCM 44.11 Water table depth � 20 :i SEPTIC TANK ❑ Type/Mfgi'L Capacity MAID No. Compartments � PKG. TREATMENT PLT. ❑ - ' ,,'' Method of Disposal st: Distance to neareWell ', ^-RC1 Foundation 4e Property Line 34W LEACHING LINE Lst'No. & Length of lines Z" Total length/size FILTER SED ❑ Distance to nearest: Well 7 16 Foundation 40 Property Line 100 I i1 SEEPAGE PITS I I Depth 2 5 Size 3411 Number Z_ SUMPS ❑ Distance to nearest: Well 2 ,16 Foundation Property Line J DISPOSAL PONDS ❑ I hereby certify that 1 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. I 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 compenw. tion laws of Calif nia." The applica,/nt rfJ+ t cell f equire spect . Complete drawing on reverse side. Signed X ""`'' Title: D W M 6'Z Date: t L z 4 R DEPARTMENT USE ONLY ��V Application Accepted by 'd --✓ Date Area / T Pit or Grout Inspection by ata Final Inspection by Date ''(/(('`++�/�//—�,I /�rl lJJ Additional Comments: • ❑ Stk 466-6181 ❑ Lodi 369-3621 D Manteca 823-7106 O Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 r ,NFO A,fMOU�N�T DUE AMODUNTnREMITTED nC/�ASH �}R�E/CEI�VjE)D eV DATE PErtRMIT NO. r.EN 1111 ifltV.6x51 7A'i,,'D �UPCi (1j 6T fl lllvfl/V EN 1410 /