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APPLICATION FOR PERMIT v " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (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 Lot Size PM Owner's Names- ll6 �C`3L Address Phone Contractor 6 Y I Address � License No,3e7 -7S 7-( 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications } ❑ Public ❑ Other I n Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material )top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION UY DESTRUCTION I I INo septic system permitted if public sewer is 1 available within 200 feet.), Installation will serve: Residence Commercial— Other t Number of living units: Numberedrooms_i, -._ ;r Character of soil to a depth of 3 feet: i of � _ - L DA-�1 Water table depth SEPTIC TANK s I 1 •❑"' Type/Mfg ' '�^. Capacity No. Compartments PKG. TREATMENT PLT. ❑ J `', Method of Disposal Distance to nearest: Well Foundation Property Line 7 ;f LEACHING LINE 1 L!No- & Length of lines.-= � .Total length/size U0 v —FILTER BED v ❑ Distance to nearest: 'I•"Well�.�0 'Foundation NX0' Property Line SEEPAGE PITS 11 Depth f 0 Size_.2X /0 /5 I Number / SUMPS f It6i`stance to nearest: Wel{ 140 I Foundation 70 7 Property Line DISPOSAL PONDS V ❑ r I hereby certify thatt'have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I rules and regulations,of the San Joaquin Local Health.-District. -- + Horne 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-contracting signature certifies the following: "I certify that-in'thW performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California," N The applicant vaust calf for all r quire inspections. Complete drawing on reverse side. Signed X- Title:�. Gd�,(l��G Date: a FOR DEPARTMENT USE ONLY v -Application Accepted Date _I 11 U 1G 7 . .(,�' Area Pit or Grout Inspection by Date Final inspection by` Y1n C13� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manieca'`823-7104 "'^ Ei Tracy 835-6385 f Applicant- Return all copies to: Environmental Health Permit/SBrvicas 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE aPEEHMIT'NO. r. ` EH -Z4lREY.iinsl 0 1 4-Z9 J. EH 1 V 1/tomo