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i z - A PPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL-1 ON AVE., STOCKTON, CA F ILE C Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the Sart Joaquin Local Health District for a permit to construct and/or install the i nS ; This application IS made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862.for well/pump and the Ru eS ne Joaquin Local Health District. Job Address �9 t G+ City L)Joe- Job OC SIJ Lot Size_��`� PM Owner's Name �0 CL�_ — Address Phone Contractor ddress � License No. .3D:��iZ/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONST 14N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca . of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Del Depth of Grout Seal Type of Grout ❑ Irrigation - Approx. Depth stern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well DZ Sealing Material (top 50') r Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION 9 DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence_ Commercial -Other c Number of living units: Number of bedrooms / • Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity 1LLP 0 No. Compartments 2--- PKG. TREATMENT PLT. Method of Disposal Distance to nearest: s :Well `FburidationL' Property Line_yE� LEACHING LINE E"o. & Length of lines ' Total length/size d 1 " FILTER BED Li—Distance to nearest: Weil 0 Foundation 1 Property Line !,I O d Fl rr SEEPAGE PITS Depth 2 l .Size Number,✓< SUMPS El Distance to nearest: Well ',170.1 Foundation 1 f 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 hifing or sub contracting signature certifies the following:"I cerfdy 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 aired inspections. Complete,drawing on reverse side. Signed Y Title: Date: y 7,. FOR DEPARTMENT USE ONLY Application Accepted by Date Area ., O ZA Pit or Grout Inspection by Date Final Inspection I Date Additional Comments: ❑ Stk 466=6781 ❑ Lodi 3693621 -❑ Manteca'823=7104" 0 Tracy-8354M, Applicant- Return all copies to: Environmental Health Permit/Seryices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24(REV.1/e sl EH 1426 ..