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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T 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 Rules and Regulations of the San Joaquin Local Health District. +- 1 ` . 1 _ (}__ _ _1 _ ,, Job Address 55 73 W, W(TCIrLIXln-�t PA4T_ Ci , Loi SizeO �� PM Owner's Name ! Address 5S13 Lit LjNqGu+ . Phone �f ConlracttSr�+-F'VLI� .0 t4 JC l;oAddress ' •� �� L 10 (JC.O License No. J�a 21 Phon 69—S r oS TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ `DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Qt 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 "4' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1"1 Public H Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation -__ Approx- Depth i I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H-P_ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth TZ Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 EPAIR ADDITION34 OBSTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial—Other Number of Living units: _L_ Number o oor s �7 # Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK X Type/Mfg Capacity 1600 No. Compartments PKG, TREATMENT PLT. Cl / t Method of Disposal Distance to nearest: Well -5! Foundation , y Q �y� Property Line LEACHING LINE 6yc No- 8 Length of lines Q Total length/size(00 X CR FILTER BED ❑ Distance to nearest. Well f f)r Foundation 10' Property Line SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Dittrict. 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 applicant st call fired inspections- Complete drawing on Feve`r� Signed X Title: .. Vt Date: FOR DEPARTMENT USE ONLY Application Accepted by Date LA__ _C719 A►ea z Pit or Grout Inspection by Date Final inspection by�__t6 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. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTER CK f RECEIVED 8Y DATE PERMIT'NO. INFO __. !I// /1 tl ( _ i s r d "m 7 12 C"rr. /-)- 7a 11