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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 'I 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. I Job Address 4N ar►Nicd` r 1-- City fj7 Lot Size PM Owner's Name _ 1�_>�r c] Address � '►�f�q Phhone Contractor L t ,r 3 Address N6 �� l�7 1 License No. a o�Phone — .-.TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ `;'-DISTANCE TO NEAREST:-SEPTIC TANK"" _v""—"""SEWER LINES' '+"'""'*""—"" DISPOSAi-FL'D'n--PROP.,-L`INE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing # r ' 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of-Casing Specifications i I'l Public M Other t ❑ Deliaf f Dep 'T.Grout Seal Type of Grout F I I Irrigation --Approx. Depth I I Eastern s 'Surface Seal Installed by _ 1 Repair Work Done ❑ Type of Pump H,P.> State Work Done Well Destruction ❑ Well Diameter, Sealing Material lloV501)'"'"" 6epth Filler Material{Below 50') "` TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i.I DESTRUCTION PIRo septic system permitted if public sewer is { $ ; available within 200 feet.) !f = Installation will serve: Residence Commercial_ Other dd Number of living units: Number of bedrooms.__17.__-___..._ t t Character of soil to a depth of 3 feet: s'4'.ti�y LOO-nI_, 1 Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT. 01 Method of Disposal # Distance to nearest: Well Foundation Property Line b LEACHING LINE ❑„ No. & Length„of,lines otal.length%size1 1. FILTER tBED ❑1 Distance to nearest: Well -Foundation Property Line r t F SEEPAGE PITS i I Depth r Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ _f I F 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 r rules and regulations of the San Joaquin Local Health District. s 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." f 1 The applicant must call for all requi ed inspections. Complete drawing on reverse side. Signed X Title: Jf7�9�rr��' b Date: ) b FOR DEPARTMENT USE ONLY 4/11 in 4 Application Accepted by 4 Date Area � Pit or Grout Inspection by Date Final Inspection by - Date t] Additional Comments— ❑ Stk 466-6781 ❑ fodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 T Appticant - Return all copies to: Environmental Health Permit/Serv.ices.1601.E._Hazelton Ave.,..P.O..Box 2009,..Stk.,.,CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH r'RECEIVED BY DATE PERMIT'NO. + EH 14-2aIREV.riHs1 ]