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APPLICATION FOR PERMIT h SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA t Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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 I 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 I Local Health District. _ Job Address .� O !1' D W e 4 fJ City/ v� Lot Size PM I Owner's Name Tri GAY 6,"VW07 4 Address SEt.�a Phone �/ _ Contractor�(2_& VW :f—Address "0-2 dE' ^��Ue9a�1 'j License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ It PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ``A'GRiCULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial (] Open Bottom ❑ Manteca �:• � Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy— Type of Casing Specifications I I'I Public Cl Other 17 Delta Depth of Grout Seal Type of Grout _ I I Irtigation _Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ 'Type of Pump •, H.P. State Work Done _ Well Destruction O We11 Diameter Sealing Material (top 501 Depth Filler Material (Below 501 -- TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is _ j available within 200 feet.) Installation will serve: Residence— Commercial_/_ Other Number of living units: Number of bedrooms�1j'�'fiOvlp r `��ThM 7 �. i Water table depth Character of soil to a depth of 3 feet: l SEPTIC TANK ❑ 3Yype/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑.,�Jl Method of Disposal --Distance to nearest: Well 44kc- Foundation.. Property Line A LEACHING LINE ❑ ..NO. & Length of lines Total length/size FILTER BED 'Distance to nearest: Well 1�v(!1.jc Foundation /G Property Line 34 z r �,� I SEEPAGE PITS I I ..Depth Size Number SUMPS Cl .'Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ r , 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, ar 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 shat)n� employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatu 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 compens tion laws of California." 4" I r The applicant mu call for all required inspections. Complete drawing on reverse side. Title: Date: Signed X FOR DEPARTMENT USE ONLY s e � Date TJ ( Area 1 Application Accepted by • Date Final Inspection by �� Date 1 Pit or Grout Inspection by Additional Comments: ❑ Stk 466-6781 O 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 95201 Z FEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. .. INFO � a +.EH 112 IREV.1/M 51