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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZE,TON AVE., STOCKTON, CA Telephone (2091 466-6781 t PERMIT EXPIRES 1'YEAR FROM DATE ISSUED �. (Complete in Triplicate! j Application is hereby made to the San. 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. Joh Address City COD) Lot Size PM I r 1I Address •� Phone . bwner's Name Conlractor, �)p1 T--` )iP'lAddress icense No. PhOne ` A-fS TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION OTHER ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ DISTANCE TO NEAREST: SEPTIC//TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATf�O"N" AGRICULTURE WELL OTHER,WELI• _ PITS/SUMPS r NTENDED USE ITjYPE OF WELL- PROBLEM AREA CONSTRUCTION SPECIFICATIOFds j Open❑ Indi LlBottom ❑ Manteca Dia. of Well E.cavatioh lstrial � Dia. of Well Casing Type of Casin Specifications ❑ Domestic/Private ❑Gravel Pack ❑Tracy "Depth of Grout Seal Type of Grout g , j4 I'1 Public ❑Other ❑ Delta Dept I I Irrigation _Approa. Depth 1 I Eastern Suriace Seal Installed by Repair Work Done ❑ Type of Pump , HI % State Work Done Well Destruction O Well Diameter Sealing Material Itop 501 . . - Depth - Filler Material(Below 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION 114avaiiablelwthine200 feet.) it public sewer is Installation will serve: Residence COmmercial Other / ! r •' Number of living units: !umber of bedrooms �' /� _ Character of soil to a depth of 3 feet: 1 % Water table depth SEPTIC TANK ❑ Type/Mf , • - / Capacty.� No. Compartments - I 'S ,,s4 \� �'t' ; T` Method of D' sal • ' 4 PKG. TREATMENT PLT.❑ 1� - -1- � /.�J'� � p� DWI.C'e to nearest: /ell Foundatl SL._.Property Line 4>L �: r s i LEACHING LINE '1�4�µ1. lf$-Length of lanes l T taLfangth/size AA Py FILTER BED O—Didtai ce to nearese I well Foundation ro Pert Y Line SEEPAGE PITS d 'Depth r Sizes Number Y SUMPS ❑ Dista n to nearest: ell Foundation �— `+ DISPOSAL PONDS '❑ 1 •- - 1A 29e` !" I hereby certify that t have prepared rhis.application and that the work will be d ne in accordance with San Joaquin county ordinances, stare laws,and rules and regulations of the San Joaquin Local Health D3trlct. J ,y; 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 np[ employ person in such planner as to become subject to workman's compensation laws of California."'Contractdls hiring or sub-contracting signature .I certifies t - inti., "1'ce 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 Car ia." The applicant IT, t c for at re ;ire n I o p to r wing on revprsa side. _ — Sig .- e: / Dale: 1:Fr. DEPARTMENT USE ONLY Z__ t Date rC____ Area ..�.t J Application Accepted by - a e' Final Inspection b Dat f' r Grout Inspection jay . Additional Comments: ❑ Stk 466-V81 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 Applicant- Return all copies to: Environmental Health Permt/Services 1601 E. Hazelton Ave., P.O. Bo:2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED aY DATE PERMIT NO. INFO CASH • aN 13-24 3-24(REV.Irx el ��