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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. T Job Address 4 0AJE1 —/}�rr 4J CittyL-0" Lot Size_ PM Owner's Name • G rf= E Address 3 ! -19 15 FYF l-kO L} Phone J~ _ Contractor EF: : Ia LT'kiK A dress 7�g_.Phone 9 ( �--� - .License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. Of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications O Public ❑ Other O Delta Depth of Grout Seal Type of Grout O Irrigation --Approx. Depth O Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. Slate Work Dona Well DeaWetidn ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material(Bielow S0') TYPE OF SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will genre: Residence ��COmmercial_ Other available within 200 feet.) Number of living units:-]— Number of bedrooms :3 , — Character of soil to a depth of 3 feet: S` 1 O - Water table depth_ SEPTIC TANK 6---(ype/Mfg capacity No.No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest::1 a Welk�.Foundation 1,5V Property Live DD LEACHING LINE qj,416. 8 Length of lines Total length/size__ f{ �� FILTER RED �O Distance to nearest: Well' S'10 Foundation 'd\Qn Property Line sa 1 SEEPAGE PITS ❑ Depth Size �x K410 Number SUMPS <Di itance to nearest: Well / Foundation Property Line DISPOSAL PONDS ❑ 1� . . 1 t I I hereby certify that I have prepared this application and that the work will be done in accordance with San rules and regulations of the San Joaquin Local Health District. t' ,Joaquin umy ordinances, state laws, and 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 a y any person In such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certif he following:"l artify that in the performance of the work for which this permit is issued, I shall employ Persons subject to workman's compenaa- tion laws California." \ ' The appiican st II for req 'ad in ti n . p drawing on reverse aide. Sign Title: /7"Y7 r,Pyi_ // ✓]�� a -3 Date: FO ARTMENT USE ONLY I ' Application Accepted y �� —, Date Area e Pit or Grout Inspect y Date Final Inspection by r Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 O Tracy 83546385 Applicant - Return all copies to: Environmental Health Permit/Services 1001 E. Hazelton Ave., P.O. Box 2009, Stk., CA 98201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECENFA BY DATE PERMIYNO. Ell Z25raev. as 7o •aU (p0lz jAJb (Z-3% �'/SSI EH ra-m