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APPLICATION FOR PERMIT 7�s SAN JOAQUIN LOCAL HEALTH DISTRfCT 1603 E. HAZE T ON AVE., STOCKTON, CA Telephone (2091 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•.Country Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address .� Citu ` `v Lot Size ` PM f�J , Owner's Name Address _ ...• n Phone Contractor; �n �!� Address 't'� -' License No:2 72 � Phone TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT 13 DESTRUCTION i] PUMP INSTALLATION [I SYSTEM REPAIR n 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 Industrial ❑ Open Bottom U Manteca Dia. of Well Excavation Dia. of Well Casing \\I{ L._i Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i 1 Public 1-1 Other 177. Delta Depth of Grout Seal Type of Grout I I Irrigation _._ Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done I] Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filter Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Cr REPAIR/ADDITION I i DESTRUCTION i I (No septic system permitted if public sewer is ,/' available within 200 feet.) Installation will serve: Residence± Commercial_ Other _ Number of living units: I Number of bedrooms ,11.5 z Character of soil to a depth of 3 feet: /2L� ') s�r� / C 9� Water table depth SEPTIC TANK ❑ Type/Mfg �/24s a1,�C,' 11�.r, � Capacity_.-/,,/_,L24:7)_ No. Compartments PKG. TREATMENT PLT.L1 Method of Disposal Distance to nearest: Well Foundation_ /t✓ Property Line Za ve- LEACHING LINE Ll No. & Length of lines r� l / �� — � Total length/size FILTER BED ❑ Distance to nearest: Well r Foundation Property Line SEEPAGE PITS -yq- Depth Size N mbar . SUMPS L.I Distance to nearest: Well ZT-0 Foundation__Z0 /- 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; "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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant;�ust call If all raga` it inspections. Complete drawing on reverse side. / X Signed Title: J' g Date: n r �r� FOR DEPARTMENT USE ONLY ` _ L r Application Accepted by `�—"~-- Date L G —�4 Area Pit or Grout Inspection b ) / -�:•�� /!i'!�i'�` �� ',�,. >j f•�� � Y � J, ,-�--- Date e; Final Inspection by��. �.� Date r 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 REMITTED CK INFO CASH RECEIVED BY DATE PERMIT-NO. EH 1124(RFV,i,n 0) y(J EM 1429 `f r� rj