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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Healffi'Distrii f fiir a permit-to cconstruct 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. Job Address ��✓� r A/Sew City Lot Size `�~ yGz PM Owner's Name a�"'-Y f eA0'C >1,JC/I(fdro Address' srAM � Phone ContractorAV7' r -f �O�Y Address &a WO UA"7 44L-*F License No.")P' 87/ Phone ,.TYPE OF WELL/PUMP: _NEW WELL ❑ a WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK' '-'SEINER CINES—_7 DISPOSAL FLD.- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA, CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of-Well Excavation Dia. of Well Casing ED Domestic/Private -❑ Gravel Pack ^-- ❑ Tracy j,Type of Casing Specifications F1 Public ❑ Other Cl Delta- Depth of Grout Seal �` �' Type 6f'Grout I Irrigation F —.Approx. Depth l I Eastern, �_..- „.e Surface Seal Installed by _ Repair Work Done CJ Type of Pump H,P. State Work Done Weil Destruction © Well Diameter Sealing Material Itop 501 �— _Depth '}'"t ..y �' Filler Material IBelow 50') AA TYPE OF SEPTIC WORK: NEW INSTALLATION I] ,REPAIR/ADDITION i l DESTRUCTION ! I (No septic system permitted if public sewer is 4 s f t available within 200 feet.), Installation will serve: Residence Commercial— Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: " Water table depth SEPTIC TANK .r F ❑ 'Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ..Foundation Property Line LEACHING LINE i kf No. & Length of lines `Jrt Total length/size l FILTER BED ❑ Distance to nearest: Well �' Foundation Property Line z' r _ SEEPAGE PITS I I Depth Size Number t SUMPS z 0 Distance to nearest: Well Foundation s Property Line DISPOSAL PONDS x ❑ hereby certify that I have prepared this application and-that-the-work-will-be'done-in-accordan'ce 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'l F The applicant must Lail for all required inspections. Complete drawing on reverse side. - Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by � Date - Final Inspection by Date" Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantecai'823-7104 ❑ Tracy 635-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDO RECEIVED BY DATE --PERMIT:NOL— - -�-- -^- INFO r + EH 13-24(REV.FiH5) I^^-'7��o, ; /C"� 'c C1lAl - EH 14.26 �► ! v`- 117Z 99 8')A -