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_ 1 APPLICATION FOR,PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 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 City `�/_s> Lot PM /Size .C �9C— Owner's Name F'Yl �� /t/flE� f.lJo�LAddress .�� IlJI s L BN RV AZA Phone Contractor ./� �i_rcArAddress -�' �d License No..Z,&QM 0. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL .- OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia" of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout p I Irrigation --Approx. Depth I I Eastern Surface Seal Installed,by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth '- ; Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I i (No septic system permitted if public sewer is d . ; available within 200 feet.) 0 s Installation will serve: Residence A' Commercial %�Other Number of living units: Number of'bedrooms; f r a Character of soil to a depth of 3 feet: V Water table depth SEPTIC TANK ❑ Type/Mfg �L�� Capacity No. Compartments 3 PKG. TREATMENT PLT. ❑ s_ r-- Method of Disposal Distance to nearest: Well 460`r Foundation P':� Property Line t LEACHING LINE °6 No. & Length of:lines — i /❑, g ��- �_ Total length/size FILTER BED Distance to nearest: well'_ Foundation Property Line SEEPAGE PITS I I Depth A(2,'-7- Size '5!� y Number ; �J SUMPSDistance to nearest: Well f✓O/-_ Foundation' O Property Line ,Zs —V DISPOSAL PONDS ❑ ! ;; 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"Diltrict. 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 tc workmn a '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." 3 The applicant must call or all required inspections. Complete drawing on reverse side. Signed X-- t s� d 3 ..�Title: Date: 1 E FOR DEPARTMENT USE ONLY., y.�et„ r '” AY.Anaa `�Application Accepted byDate 1w+ Pit or Grout Inspection by f Date Final Inspection Date. 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 z t i FEE AMOUNT DUE MOUN:r-REMITTED . CK RECEIVED BY- - -+ --INFO -r .'^A:_ rCA5H ; TE-�.,- PERMfT=iVO" r.EH 13-24(REV.1/n s) ...�.� xt W �y 1 ��w- ',�t„�• ^�"' f EH 14-29 .r+..