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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E: HAZE TOWAVIE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l 4 (Complete in Triplicate) i Application is hereby made to the San,Jaaquin 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ' Job Address 1 M/�] v City� Lot Size PM 111 Owner's Nam + p ' n A res s f flone� Contractpt� Address" Lit ense Hit: Phone TYPE ;NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' s {� _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS { r INTENDED USE TYPE OGW*EtL�- PROBLEM AREA CONSTRUCTION SPECIFICATION a .❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of V#*Excavation Dia. of Well Casing ❑ Dorrrestic/Private ❑ Gravel Pack 11 Tracy Type of Casing Specifications X*M�f�{"`�'1f f-1 Other ❑ Delta Depth'.of Grout'Seal ,F Type of Grout 6ft&"A,;t I I Irrigation _.Apprax. Depth I I Eastern Surface Seal Installed by -, _ ° J - Repair Work Done—L7- -Type of-Pump• -H..P - - State Work Done_---P11f Well Destruction F1 Weil Diameter Sealing Material (top 50') f rt lop ' s epth Filler Material (Below 50'j i k TYPE OF SEPTIC WORIW NEW INSTALLATION I l REPAIR/ADDITION L1 DESTRUCTION l 1 (No septic system permitted if public sewer is) available within 200 feet.) t { Installation will serve: Residence Commercial_ Other 4 E •.ti3_ Number of living units: Number of bedrooms � t} Character of soil to a depth of 3 feet: Water table--depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments j PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Well Foundation Property Line 1• - 4 4 Y � ..-, :�+.�-...�..w��-� y�..t �.-_...,.+w..'w�.-.-+�,..1,�=�=+r-W..-ti+w.•.��.«w.-a�r �+.,._-.w�...'wv�.K ....-:.1+-:` -`�Y' I LEACHING LINE ❑ No. & Length of lines ` `!t _ *` -"r YTotal length/size 1 WFILTER BED ❑ Distance to nearest: Well r Foundation f Property Liner —SEEPAGE PITSi I De. p Size ^ter----6i th � Number-' i SUMPS Cl Distance to nearest: Well -Foiindationr T 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 i employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contractingesignature certifies the following: "I certify that in the performance of the work for which this,permit is issued,l shall employ,persgns-subject to workman's compensa- t tionlaws of ornia." -, The app m t Cal Ufo al equir i spections ompleta drawing on reverside. G�' Signed ZA isle: ) Date: / FOR DEPARTMENT USE ONLY Application Accepted by Date xlu a Area Pit or Grout Inspection by D Final Inspection b � Date� / I 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 I jFEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. r INFO ry� + EH 13.24{REV,f/K 51 EH 1428