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APPLICATION FOR PERMIT .R SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 } PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is de 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 -cal Health District. /? 1R Job Address 10/ �' �� ' - City T-pt ly1 Lot Sizef7f✓ /• v' PM f"1 eMk r � - f c�H�S� �e Owner's Name _JI .� o`r54ddress �+� � � Phone Contractor 51✓0 Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAI OTHER ❑ DISTANCE TO !NEAREST: SEPTIC TANK ----SEWER LINES DISPOSAL FLO. PROP. LINE - - FOUNDATION AGRIC RE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 0 Manteca ia. of ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack P Tracy Type of Ca Specifications fl Public 17 Other ❑ Delta Depth of Grout Type of Grout I I Irrigation _--Approx. Depth I I Easte Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is �- r )I available within 200 feet I Installation will serve: Residence Commercial— Other' Number of living units: _1Z Number of bedroorr f Q s Character of soil to a depth of 3 feet: A�o Y, Water table depth SEPTIC TANK ❑ Type/Mfg PAcLOT Lent .Te Capacity 1.206 No. Compartments 4 PKG. TREATMENT PLT..❑ Method of Disvosal Distance-to nearest: Well __ f Foundation _�0 Property Line 3 i'. LEACHING.LINE ❑ No. & Length of lines ch gs-G 70 Total length/size FILTER BED ❑ Distance to_nearest: Well Foundation Property Line � . SEEPAGE PITS ( I Depth 2 5 ,�0� Size�.�._3 Number Zook }-f ea 3rr i SUMPS LlDistance to nearest: Wel! 1_1�AV Foundation tidt 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: 1 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 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 for all required inspections. Complete drawing on reverse side. �Q Signed Title: Date: y��+ 2z/W F F D/EPARTE_NT USE ONLY {{ Application Accepted by /`-� Date Z7- O Area " Pit or Grout Inspection by {J Dp Fin I Inspection by Date/ Additional Comments: e V (o �T Z -73—J ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 DUEAMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO { EH13-24 IFEV.Fiu5) �'�� -�. �Q �2 1Q 14-2gi k' 97.38