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' APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT = 1601 E. HAZE 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 /� s�.� So, 141 6 1,Hkdf Ooe, City—PoN Lot Size 490 4,1 )Otwyei r7 ` PM Owner's Name _R;r v ee �y/y Address AH.4tie Phone Contractor 41 7b q1lll J4Q*VAddress � Phone License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT q DESTRUCTION ❑ PUMP'INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ *' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL----!!'--F---PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavations Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specificationst i'1 Public n Other ❑ Delta Depth of Grout Seal Type of Grout' —.—.— I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by 1 Repair Work Done ElType of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 1 Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I Wo septic system permitted'if'public sewer is available within 200 feet.) Installation will serve: Residence Commercial OtherLU Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 5/�lOrCi� Water table depth ;X& 1 SEPTIC TANK Z Type/Mfg pVe Coq 0r Ct9eI/C: Capacity—L-A-00 No. Compartments X PKG. TREATMENT PLT. ❑ x f Method of Disposal i— a Distance to nearest: Well -fid Foundation /o Property Liner a]14 t LEACHING LINE 0 No.r& Length of lines Total length/size ^+ � .� U t FILTER BED i --.�—. �) Distan�e to nea�st: Well 9p Foundation .�S Property Line 10�l •r, X Yn . I , SEEPAGE PITS I I Depth Size :Number SUMPS CI Distance to n"e Fe-s_f"" Well w Foundation J Property Line ;4 DISPOSAL PONDS ❑ j ,�, 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, an 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 to workman's compensation laws of California."Contractor's hiring or sub-convecting signature certifies the fallowing: "!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 1 The applicant must call for all required inspections.-Complete drawing on reverse side. " "— ^ _ # Signed f Title: Date: .0.X 4—` r R DEPARTMENT USE ONLY I Application Accepted by DateP .w• Pit or GYout.Inspection by Dare Final Inspection by �- 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 t .I FEE AMOUNT DUE AMOUNT rtEMITTED K INFO C H RECEIVED BY DATE { PERMIT'NO, t f t-EH 13-24IREV.I/e51 EH 14-28 � ��