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` APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 rnadain 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. Job Address `�'�/� 9'/f�.Y City r~ Lot Size "yeAr-s PM E }1 I�/ ��e. S f�l�Y ld Owner's Name _ /�lGtL_ Address Phone T f � Contractor Address ll /P/ -?1 7� �c�'dI� License No. Phone J+ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC MENT ❑ 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 ' p Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r p Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t r'7 Public ❑ Other C] pelta Depth of Grout Seat Type of Grout I I Irrigation _Approx. Depth l ] Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. . State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION - REPAIR/ADDITION 1.1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other O � Number of living units: n Number of bedrooms ® �" Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity_k?.9�O_ No. Compartments �r PKG. TREATMENT PLT.CI t Method of Disport I Distance to nearest: Well Foundation Property Line Ls:_ LEACHING LINE No. & Length of lines Total length/size t.Lr, FILTER BED ❑ Distance to nearest: Well� o Foundation 4-t Property Line SEEPAGE PITS Depth "Z,��Size � Number SUMPS Distance to nearest: Well Foundation 348 C Property Line ��y r i DISPOSAL PONDS ❑ 1 hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state4and 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 hiring or subcontracting signature Certifies 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." The applica ust call f4 r quired inspections. Complete drawing on reverse side. Signed X� C c3— — Title: Date: . �3 " dFOR.DEPARTMENT USE ONLY Application Accepted by Date'"-2- LS—(�n AreaUL Pi or Grout Inspection byDate Final Inspection bf�� l�i/��/acme-�1Dafe� { ' V Additional Comments: ❑ Stk 466-6781- ❑ Lodi 369-3621 O Manteca 823-7104 ❑Tracy. 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 .E. Hazelton Ave., P.O. Box 2009, Stk.,�CA 9520FEE1 )NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIS'NO. �; EEK H14-26 Ev,1/H5i