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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' ( t 1601 E. HAZELTON 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 _/_V _ A__/ City -S F11'/-C-1 Lot Size PM Owner's Name �_5 ' �l /� 2_ Address 5"'��% r � } 1 Phone Contractor ='A dress C� _ /e `itJ Gt v ansa No- 5 '�, �`i'3 . Phone ----1 TYPE OF WELL/PUMP; NEW WELL n WELL REPLACEMENT ❑ DESTRUCTION D - PUMP INSTALLATION [I SYSTEM REPAIR (l OTHER ❑ DISTANCE 70 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 I.1 Industrial I I Open Bottom 11 Manteca : Dia. of Wet! Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I l Public ❑ Other . (]-Delta Depth of Grout Sea! Type of Grout_ Ll Irrigation —Approx. Depth , I-] Eastern Surface Seal Installed.by Repair Work Done 1.1 Type of Pump H,P. State Work Done Well Destruction I_] Well Diameter Sealing Material {top 50'1 Depth Filler Material {Below 50'1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION (-I REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.I installation will serve: Residence_X_ Commercial _ Other Number of living units: __J__ Number of bedrooms 3,, .- Character of soil to a depth of 3 feet: G L Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Ll • Method of Disposal Distance to nearest: t Well IPZ. ' Foundation , G% Property Line LEACHING LINE No. & Length of lines �— SOr 60- 9 Total length I size_, U z FILTER BED 1-1 Distance to nearest: Wel! / Foundation / Property Line SEEPAGE PITS ,Q Depth Size �rT Number L SUMPS t1 Distance to nearest: Well Foundation _ Property Line _ r DISPOSAL PONDS 1.1 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. ,t Home owner or licensed agent's signature certifies the following: "I cerlify 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 worts for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse si e. tt,�� % Signed X r ., � Title: C s�� t— ��-z U .--... ----- Hate: FOR DEPARTMENT USE ONLY Application Accepted by Date �`ZZ`" r Area //� ,[ Pit or Grout Inspection by /�� Dat final Inspection by _ Date ry0r/_?� Additional Comments: r�VL`L}1�-�. tplicant Stk 466-6781 EILodi 369-3621 ElManteca 623-7104 3 Tracy 83- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CFEE �f INFO AMOUNT{{DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT NO. a EH 13.24(REV,1 4 51 EH 1429