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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 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ig'V 'Wh City h-C%W,40 Lot Size *7.j":- 2 C ® PM Owner's Name .[ AiE X O'AF09'A- ,V Address d'J3/ Phone Contractor's Name • /� �� +s� icense No. 2-S^�/ ' �Y3 Phone 7p� d TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PERMIT'NO. PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE c FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTIfGED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well -Casing - ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 4 ❑ Other gel Delta Depth of Grout Seal i Type of Grout F-1Irrigation—Approx. Depth ElEastern _ Surface Seal Installed by Repair Work Dane ❑ Type of Pump �:P_ State Work Done Well Destruction ❑ Well Diameter —Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residenci___Wl_ 'Corninercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet ' Water table depth 6 SEPTIC TANK irType/Mfg /p°/�i�iE'�+f/� Capacity / Z 00 No. Compartments PKG. TREATMENT PLT. ❑ w Method of Disposal fi 'und'ation O Distance to nearest: Wells Fo^/ Property Line �tD LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth 2 Size }C' Number SUMPS Distance to nearest: Well _S`D 7 Foundation ;! O Property Line .62/ DISPOSAL PONDS ❑ ' i- 06 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 call for all'required inspections. Complete drawing on 2W� Signed X_ �/.f' _ Title: Date: r , JF�DEPARTM USE ONLY Application Accepted by l� Date ` ` Area J� Pit or r ut Ins c 'on by Date�.4 Y Final Inspection by�"�� " / ��U% Date (� tAl Additional Comments: �' LC A ❑ Stk 466-6781 ❑ Lodi 369-3621- — 0 Manteca 823-7104 ❑ Tracy 835 -MM 07"A A.4i &,,o-/✓ G Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 /, EH 13-241REV. 10/831 iH 14 28 FEE INFO AMObNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE` PERMIT'NO. 1+ c ' 1r �-l5- 84 � 15-1 i