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i I i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED I (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.648 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin ` Local Health District. Job Address ' City Lot Size PM 00 1" Owner's Name/� �-1�--r dress 'I 2 Phone d Contractor y r s 7 Lie erise o. ^� 't Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DEST UCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ -L OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE '`�— � y. 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 c3❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _-Approx. Depth ,,,Q Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. State Work Dona Well Destruction ❑ Well Diameters Sealing(Material hop 50'1 Depthr Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALIATI0N 5K REPAIR/ADDITION ❑ (DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence L' Commercial— Other e Number of living units:3�� dumber of bedrooms JJC3C'� + �f`� Dc`��2�� +t �CdwtiC. s Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK Type/Mfg A—&&-des�l_(.0414 ick_Capacity _ rNo. Compattrnents ' PKG. TREATMENT PLT.-P" t 'Itt-4ey-Soo-SS'O V44IO'9 .Method of Disposal ` t 1 Distance to nearest: i /Well Foundation Property Line j d .LEACHING LINE •El No. &Length of lines Total length/size - FILTER BED ; ❑ Distance toi nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number • SUMPS ;0 Distance to nearest: Well Foundation PropertyLinet _ DISPOSAL PONDS :❑ ' I hereby certify that I have prepared this application and that the work will be done it 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:"l 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."Contractors hiring or sub-contracting 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 applicant ust call r all uir d In tions. Complete drawing on rave side. Signed 1 Trtle: — Data: /0 " l � � 1 t t i t FOR DEPARTMENT USE ONLY r d f Area -2 Application Accepted by Date '- Pit or Grout Inspection by Date — Final Inspection by Data Additional Comments:1+t�f' ❑Stk 486-8781 ❑ Lodi 38843621 ❑ Manteca 623-7104 ❑ Trac 835-8386.fed + Crve-p ,Mw o+r r&<, Applicant-Return all oples to. Environmental Health Per it/gervices 1601 E. Hexelton Ave., P.O. Box 20M,.Stk., CA 95201 ell aQ4 FEE AMOUNT DUE AMOUNT REMITTEDINFO CASH RECEIVED BY DATE PEAMI7 NO. EN 13•24IREV.1156) Ek tail �,? Q S Gj:-2�SYG .sia��fJ�>j�i..�-!�/rr��,�Glrci• I