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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA +' Telephone } 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 DistrictQ02 '. A� ��1 ��t Job Address c . � _ _ 0�(• CityA,—& . Lot Size � PM Owner's Name tu"CJ'� Address Q 3 nC �Q �RJPhone L 1 --s Contractw Address PI, &.K 76 7 0(0-11-00licenseNo..?ZCZ �' Phone SU—S-/Os- TYPE TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT E) DESTRUCTION ❑ PUMP INSTALLATION D `SYSTEM REPAIR ❑ OTHER O 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 U Industrial ID Open Bottom D Manteca Dia. of Well Excavation Dia- of Well Casing 17 Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Specifications l'I Public IJ Other D Delta Depth of Grout Seal Type of Grout f I Irritlalion __.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 11 Type of Pump H.P. State Work Done Well Destruction D Well Diameter Sealing Material (top 50'l Depth Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION . REPAIR/ADDITION I ) DESTRUCTION I 1 INo septic system permitted if public sewer is }� / available within 200 feet.) Installation will serve: Residence P__11' am _ Commercial_^ Other F :5~, i Number of living units: � Number of rooms � fi � Character of soil to a depth of 3 feet: tt�--rr++�y Water table depth _ SEPTIC TANK Type/Mfg Capacity_��[Nt7_ No. Compartments PKG. TREATMENT PLT. ❑ f t Method of Disposal Distance to nearest: Well Sa Foundation 0 Property Line j LEACHING LINE No. & Length of lines Total length/size K r FILTER BED ❑ Distance to nearest: .Well�--_` Foundation W Property Line � SEEPAGE PITS N$111, Depth SizeNumber _ r SUMPS C1 Distance to nearest- Well 1l5'7� Foundation �V r Property Line b ... DISPOSAL PONOS ❑ 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 l 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 t call for ireq 'red inspections. Complete drawing on reverse si . Signed X Title: V rJ." Date: �a oc±90 i FOR DEPARTMENT USE ONLY Application Accepts by Date 00�' x' Area 12_-^ Pit r Grout Inspection by Data " %Z Final Inspection by Date � Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369.3621 O Manteca 87.3-7104 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Servicas 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE K 0 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.t/n5) EH 14.28