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APPLICATION FOR PERMIT 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.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address a 41Id ata Ud -.8 7W ,,D City Lot Size PM Owner's Name P — A4.0 t: Address, �f Phone Contractor ' . /aiz46/L Address 2 "Ord4 License No. ,15 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q 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 - 1513pen 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 Installedby Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material,(top 509 Depth Filler Material (Below 501 J TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION'❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commergial Other - Number of living units: Number of bedrooms / x/ - Character of soil to a depth of 3 feet: AQ �� Water table depth SEPTIC TANK .❑ Type/Mfg. �.1-L� Capacity ci&OOW No. Compartments PKG. TREATMENT PLT. ❑ - t PT Method of Dlspos�IT - Distance to nearest: Wel Foundation-� Property Line�� LEACHING LINE ❑ No. 8 Length of lines tf — .G � �4 F T Total length/size } FILTER BED ❑ Distance to nearest: Well _ Foundation /g2 Property Line_' SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 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 hiring or sub-contracting signature cerfi ies 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 applicant must call for /all uire spec/ttiio�ns Complete drawing on reverse side. / y Signed X � Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by All # Date ) _ 27 �� Area v/� 7/ Pit or Grout Inspection by Date Final Inspection by '9'r,60", Data 1 1] 1i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 389-3821 ❑ Manteca 8237104 ❑Tracy 835-SM - -- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INEr-O AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. D�,a-Y11ROW.,-as, �1Suo /23a-85 bis /s(� ER,aA