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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—JON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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. This4ftpplication 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. 9 S6 STo�t/t rd9 6 City TYRC Lot Size _- PM Job Address _ Owner's Name G /9 D F _ Address _ _ Phone /� /9/YTh D/✓ 9 ,Soli' Address , ` Contractor_ License No. %Y�BVI___Phone '•`•"'-'TYPE OF-WELL/PUMP: - NEW WILL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION CJ SYSTEM REPAIR ❑ OTHER ❑ 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 Ll Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia, of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing---- Specifications I Public I_t Other '�- r Delta - ~ Depth of Grout'Seal Type of Grout I I Irrigation __-_Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. _-- State Work Done _ Well Destruction ❑ Weil Diameter Sealirig Material (top 50') Depth Filler Material (Below 50'1 - ` TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION t/, DESTRUCTION I 1 }No septic system permitted it public. sewer is U available within 200 feet.) Installation will serve:' Residence Commercial_ "Other Number of living units: �_ Number of bedrooms Character of soil to a depth of 3 feet: -_y1 -. Water table depth SEPTIC TANK CJ Type/Mfg Capacity- No. Compartments _ PKG. TREATMENT PLT. ❑ 1._ " ' Method of Disposal Distance to nearest: Well Foundation Property.Line i LEACHING LINE No. & Length of lines I O_t7- Total length/size L. FILTER BED CJ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth Size _._- Number SUMPS 1-1 Distance to nearest: Well _ Foundation Property Line DISPOSAL PONDS r I hereby certify that 1 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 Sart 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 not employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub•contr'acting signature certifies the following: "I certify tftat 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." 1 The applicant mus all for all required'inspectibns.'Complete drawing on reverse side. 'r \ Signed X _ Title: L1 1 �� Oate: ~^ , r o OR DEPARTMENT USE ONLY � Date • / Area Application Accepted by !A4"� Pit or Grout Inspection by _ Date Final Inspection byOOWIF'�— Date Additional Comments: U Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Cl Tracy &35.6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO EH 13.24 IREV.,:H s-, �� —liQ DO EH 14-20