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i' APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT • 1601 E. HAZELiON 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.569 for sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. (� Job Addressrd 3Q b + .5694TI KI M);Vr �A #A City r rLot Size $ hr- • PM 1! Owners NameyhhtT?' Addressri0YyL_� Phone 77—O 23L 1 r Contractor �F-L F Address _ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ ^WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPA OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROPY FOUNDATION AGRICUL WELL OTHER WELL /SUMPS _ INTENDED USE TYPE OF WELL PRORL REA CONSTRUCTION SPECIFICATIONS - J ❑ Industrial ❑ Open Bottom anteca Die. of Well Excavation Dia.of Well Casing ❑ Domestic/Private ❑ Gravel Pac ❑Tracy Type of Casing_ Specifications " Pl Public ❑ O fl Delta Depth of Grout Seal Type of Grout_ _ I Irrigation _Approz. Depth I I Eastern Surface Seal Ins ad by ^ - Repair Work Don Type of Pump H.P. State Work Done Well Dest n ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION^ REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is > • available within 2(10 feet.) Installation will serve: Residence_ Commercial Z Other C Number of living units:—L�T Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth G SEPTIC TANK )( Type/Mfg P,)-1- Capacity 3 DO No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ^ Distance to nearest: Well Foundation Property Line U' LEACHING LINE k( No. &Length of lines b — 1490 Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation Property Line ; SEEPAGE PITS 11 Depth Size Number I' SUMPS L1 Distance to nearest: Well Foundation Property Line 3— .-j DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San JoaquinL,�bunty ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dfittrict. . Home owner or licensed agent's signature certifies the fotlowirg: "I certify that in the performance of the work for vvhlcfi'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 candies 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." 1, r The applicant st�call for I1.re(q/M�d inspections. Complete drawing on reverse side. Signed X 4,�Z•r",�/�— This: Date. �... a OR DEPARTMENT USE ONLY '1 Q� ,2 Application Accepted by Date , ` .1 n Area 2> !7 Pit or Grout Inspection �t Data Final Inspection by Dare- Additional Comments: 0.N v_ /jm IL 0 ® 4 • ❑ Stk 466-6781 ❑ Lodi 3893621 ❑ Manteca 821-7106 ❑ Tracy 8356385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE I INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE �jPERMIJT'NO..�\ a.ER 13241REV.1/xsi .EH U-26 i