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6. 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) 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. 64Job Address o?l� 7�"I C�7 xx�_� �City Lot Size PM Owner's Name ��/`"' I/nA/ddress � ' ! ,—' Phone L Contractor (,9PA) /y fj^ Address S i / "�/ License No.L2_��if_7Phone L TYPE OF WELL/PUMP: !�° NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE INTENDED USE 1. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications * Public 7.1 Other 171Delta Depth of Grout Seal Type of Grout_ I I Irrigation __Approx. Depth I 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 L Depth Filler Material (Below 50') ,�- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) V Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms 3 Character of soil to a depth of 3 feet: `pq/7'I, �� ,p Water table depth I SEPTIC TANK ❑ Type/Mfg �. �-' 61 � CapacitVl� No. Compartments V` L PKG. TREATMENT PLT. ❑ r �,ry Method of Disposal ✓� ` Distance to nearest: Well Fourldation Property Line 1 LEACHING LINE ElNo. & Length of lines _ q Total length/size FILTER BED El Distance to nearest: Well- - Foundation r�gProperty Line SEEPAGE PITS I I Depth Size Number `" SUMPS Ll Distance to nearest: Well Foundation Property Line 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 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. (' Signed X A A Title: 45 Date: b OR D./ARTMENT UE ONLY . {/'� `7 Application Accepted by '"!.g"l Date ` / Area_�/ LPit or Grout Inspection by Date Final Inspection by Date,// Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 L INFO AMOUNT DUE AMOUNT REMITTED CASHFEE CKT RECEIVED BY ( DATE PERMIT NO. La EH 12"IRE,.r i x 5, 1�� EH it-2a p