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APPLICATION FOR PERMIT 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 Hplicate) ' 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 Joaquir Local Health District. ee'' EJob Address At, �Oc Alo w e L 4 13d, City Too,ll r Lot Size PM Owner's Name T?•/ J/44LjI G> Owe7-S Address F4-"O �VeWCCC t?a' Phone iContractor ' A�'r��"y � -301►' Address 6�� gLv6gyln�fUP, License No. yYy Phone i TYPE OF WELL/PUMP: r NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O „ i, PUMP INSTALLATION LJSYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q.Jndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Z'❑'bomest:16Piivate ❑ Gravel Pack ❑ Tracy Type of Casing______.7__ Specifications »-- ' t---- T of Grout r('1 Public Q Other (:l Delta Depth of Grout Seal Type - VI I.Irrigation �,..—..Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction L1 W611 Diameter Seating Material (top 50') I `Depth �` Filler Material (Below 50') x C TYPEOF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within_200 feet.) Installation will serve: Residence Commercial Other i Number of living units: Number of bedrooms i Character..of soil to a de�tlt'of 3 feet: - -4 16 r /4"44' (1 Water table depth_ SEPTIC TANK,, (311Type/Mfg ` Capacity f' No. Compartments PKG. TREATMENT PLT. ❑P ! Method of Disposal Distance to nearest: Well Foundation - Property"Line•------- ��((} LEACHING LINE." Qt• No. & Length of lines �-' !00 t } Total Length/size 80d V •� FILTER BED . D Distance to nearest: Well l Foundation ��• Property Line �� ' SEEPAGE PITS I I Depth Size �'_ Number r' SUMPS Ll Distance to nearest: Well Foundation �. '-1 E Property Line— DISPOSAL ine,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, ai 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 n employ any person in such manner as to become subject to workman's compensation-laws of California" Contractor's hiring or subcontracting signaa 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 compenr tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side: {t Title: F Data: Signed X r r FOR DEPARTMENT USE ONLY �� z ,r = Date Area Application Accepted by Pit or Grout Inspection.by Date Final Inspection by Date r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.'Boz 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CASH.; = RECEIVED BY PATE PERMITNO. INFO ^7/� /ynj EH 13-24 IREV.1 8 5) -7/) // 1 A /lJ • l)� R22