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} APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f t 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 } PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I I (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 2�15_0 A11Z City Lot Size PM I t Owner's Name jAddress Phone i Cantra_ctor A _2{�L.�� Addres`sr CSO.! l �-•i {�d�A' License No.�7ts'3" Phone F -c, 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 i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial -•, ❑ Open Bottom CC Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel-Pack 4❑ Tracy - -Type of Casing ' Specifications r7 Public i ❑ Other -1 ❑ Delta Depth of Grout Seal Type of Grout _ " = I 1 Irrigation ;`'_ —Approx. Depth,"' l I Eastern Surface-Seal installed,by - Repair Work Done ' 11-4-Type of Pump _ H.P. t^ a State Work Done Well Destruction ! ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') � --- TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION;f,J (No septic system permitted if public sewer is i available within 200 feet.) In will serve: Residence Commercial_ Other Number of living units: I_ Number of bedrooms_-__ s Character of soil`fo a depth of 3 feet: A Water table depth ! p] t SEPTIGTANK , j ❑ Type/Mfg _ 1��-Li Capacity"/ — No. Compartments PKG. TREATMENT PLT. ❑ _ ' Method of Disposal "t r Distance to nearest: Well � Foundation_,i257 PropertyF Line A2 F77 4 LEACHING LINE -0 No. & Length of lines �` � �`_ � Total length/size r FILTER BED t r 0,; Distance to nearest: Well. /. fi Foundation_&A /'�7 - Property Line?� i \ i SEEPAGE PITS Ll Depth Size N' Number .9 SUMPS 1 f []istance to nearest: Well./64 Faundation�Alle� Property"Line DISPOSAL PONDS '. CI 1 I hereby certify that 11 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/if ensed-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 nLi-sner,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 the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- '' tion Iawsiof California." The applicant must call for II'requir d inspections. Complete drawing on reverse side. Signed XI 1. c Y Title: ' Date: .ey DEPARTMENT USE ONLY `G } Application Accepted by Date /0 Area a � . Pit or Grout Inspection by Date Final Inspection by e 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 r FEE AMOUNT DUE AMOUNT REMITTED CK 41 RECEIVED BY DATE PERMIT'NO. f _ INFO d:. 1 CASH 13,2A-IREV.144 51A ... _ -�+.: •a .,ri.n»-...�.......y.. _ ...�. EH 14-29