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l' 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 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. t/ Job Address � _ -__ -- City ■ Lot Size Ta/-h PM Owner's Name /f Address Lio`� ZPhone _ 2 / Jyy �LZ1 Phone �✓ Contractor� ` �Address License No TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll PUMP INSTALLATION ❑ SYSTEM REPAIR i_1 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 L_ Industrial Ll Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications I Public I 1 Other 1 1 Delta Depth of Grout Seal _! Type of Grout I Inrgauon Approx. Depth 1 I Eastern Surface Sedl Installed by ---- Repair Work Done Type of Pump H.P. _ _- _ _—_ State Work Done Well Destruction I_. Well Diameter Sealing Material (top 50'1 _ _--- Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence �/Commercial Other Number of living units: —A Number of bf�drr/2�oms f Character of soil to a depth of 3 feet: _.__ _'-5�1��— Water table depth_ 6 SEPTIC TANK 4 -Type/Mfg, Q�_�_ ___ Capacity 3.2tX) No. Compartments PKG. TREATMENT PLT. t 1 � Method QL,Disposal Distance to nearest: WeII Q{010 Foundation �Q / Property Line sine3f LEACHING LINE ANO. & Length of lines .C�j r Total length/size__ FILTER BED i I Distance to nearest: Well La.-20-1f Foundation ..�,� Property Line - SEEPAGE PITS I`i—Depth .2 Size — —_ Number Q — SUMPS I Distance to nearest: Well �SFoundation _714;iO Property Line�_ DISPOSAL PONDS i 1 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: "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 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 must call for all equi d inspections. Complete drawing on reverse side. Signed X _-_. Title: Aw!& __ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date _ Area or Grout Inspection by �`t,�— Date, Final Inspection by ate (Additional Comments: ❑ Stk 466-6781 O Lodi 3693621 ❑ Manteca 823.7104 L' Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boxz2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO, INFO J� //1 J� CASH Z./ell, (\ (X' /J�J Xn 7 EH 13.24 tREV.�iw•, r ! V/: �j �✓0(J *410 EH.2e VVV V