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13" APPLICATION FOR PERMIT l 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address /7-130 C,/ �O 0,'-ex- City -J�-�1�O�tJ Lot Size W4 .4c PM Owner's Name I aF Address /g'(/, 9 L o4, Phone Contractor - si w rwt Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed byt Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �. I available within 2D0 feet.), Installation will serve: Residence-IC- Commercial_ Other Number of living units: Number of bedrooms ZZ, Character of soil to a depth of 3 feet: 4mdv a 1A foAm Water table depth LV SEPTIC TANK I- Type/Mfg PJ L f c0,41.4zi! Capacity-d o O No. Compartments Z 0 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well I.PS Foundation YO Property Line �.T« % LEACHING LINE (Ir No. & Length of lines 'O Total length/size J U74 FILTER BED D Distance to nearest: Well I.IX� Foundation O � Property UmZJrS r SEEPAGE PITS ❑ Depth /D� Size IV Number / SUMPS ❑ Distance to nearest: Well.0911W Foundation /,2-: Property Line DISPOSAL PONDS ❑ a /Oe (0 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 1 rules and regulations of the San Joaquin Local Health District. ' - ' , _ Home owner or licensed agent's signature certifies the following: "I certify that irtthe performance of the work forwhicl3 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 hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which thjs' rmit is issued;l shall employ persons subject to workman's compensa- tion laws of California." 11 The applicantmustcall for all requ ed inspec ns. C mplete drawing on reverse side. Signed X--or' Title: D-cf17t-!ti Date: L� FOR DEPA TMENT USE ONLY L Application Accepted by ' \ Date Area f OV i Pit or Grout Inspection by - Date Final Inspection by ate Additional Comments: ❑ Stk 466-6781 ❑Lodi 368-3621 fiClUantece 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952131 INEEO MOUNT DUE AMOUNT REMITTED RECEIVED BY /DATE PERMITNO. . EH rM4 IRev.iia al `� -S . 7 �/ `!f.$ � 197 EH taxa