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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA t Telephone (209) 466-6781 PERMIT EXPIRES 11'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 compliaAce with San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. II �. 'TAG1L779� r City � � Lot Size A� PM Job Address II. Address /Q 7 2 i -s• T/a Gie�a�C Phone Owner's Name_+��1 Z5 II' Y7� one - Contractor 1�- X17 _12e�J Address-7 Al- AAF Z&7- )W License No. Ph 4L3� - TYPE OF WELL/PUMP: NEW WELL :3WELL REPLACEMENT [IDESTRUCTION C k I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO;NEAREST; SEPTIC TANK_ SEWER LINES _ DISPOSAL FLD. _ PROP. LINE FOUNDATION Y AGRICULTURE WELL OTHER WELL _ PITS/SUMPS _ INTENDEDUSE -TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ] Industrial 11' ❑ Open Bottom' ❑ Manteca Dia. of Well Excavation— Dia. of Well Casing C Specifications Domestic/Private 0 Gravel Pack i ❑ Tracy Type of Casing ("1Public n Other n Delta Depth of Grout Seal Type of Grout i I Irrigation ' "�"''=°TApprox"DBpth I Eastern Surface Seal Installed by------- Repair Work Done 0 . Type of Pump H.P- — State Work Done- Well Destruction ❑ Well Diameter Sealing Material IMP 50') - iI� Depth_ Filler Material (Below 50 - - - I TYPE OF SEPTIC WORK: NEW INSTALLATION N REPAIR/ADDITION I I DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence Z Commercial— Others Number of living units: _� .Number of bedrooms Character of.soil to a depth 61 3 feet: '/ GI L.Q S' Water table depth )^ SEPTIC TANK ❑ . Type/Mfg .,,�e P4-L Cap2cily-i-2-0-0 No. Compartments PKG. TREATMENT PLT.EDI tMethod of Disposal _.. Distance to nearest: ,Well _._ Foundation l +Property Line LEACHING LINE & Length of lines Total length/size / a. i FILTER BEDDistance to,nearest:earest: Well-1.lf �Foundation Property Line ��?! JC _ _.. -d b SEEPAGE PITS l , ,(z Qepth i._� Size__ _ _ Number SUMPS 1 �I' 0 Distance to nearest:` Well �� Foundation 0 PropertyLine 3 6W DISPOSA�-PONDS ❑ '�.� I hereby certify that I.have prepared,this application and that the work-will'b�'.dcne-in accordance with San Joaquin,county ordinances, state laws, and 'rules and regulations of the San Joaquin Local Health District. ".. 'A ` Home owner�ior licensed agent's signature certifies the following:-4-certify that in the performance of the work-for which this permit is issued, I shall not employ anyperson in such manner as to become subject to workman's compensation laws df California." Contractor's hiring-or subcontracting 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 compansa- tiorl laws of California!: The applicant must call fol all required-inspections. Complete drawing on reverse side. 'e- Signed Title: =Ii; Date: FOR DEPARTMENT USE ONLY- i Application bccepted by _ ; Y Date Area R- � � - 'Final fns oction by� � �-�� Qeta Pit,or•Grout Inspection by -F-Qata'- P Additional Comments: ❑ Stk 466 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trscy'835-6385% \m, Applicant -xReturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave. P.O..Box-2009, Stk.,.CA-95201 ,IFE NFO AMOUNT DUE AMOUNT REMITTED CA9H RECEIV913.BY DATE PERMIT'NO. ..EH 13.241 REV.1,n ti) Otl EM 14-29, I i.