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APPLICATION FOR PERMIT 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 —l_6 /_Q L_ Z/QAff,0-L 9 n City 4&a1 Lot Size � � 9 X ��a PM Owner's Name E Address, 5-542-9Al, SA S'T' 4,041 Phone to 7 4 Contractor F L DYP On 7) Address 4 E 7_ License No._ .�-�Y7� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 'DfSPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF,WELL -PROBLEM AREA. CONSTRUCTION SPECIFICATIONS .; ❑ Industrial ❑ Open Bottom d Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f`l Public ❑ Other ❑ Delta Depth of Grout Seal p Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. I State Work Done_ a Well Destruction L2 Well Diameter Sealing Material (top 50') Depth Filler Material 18elow150') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is ✓ I available within 200 feet.) Installation will serve: Residence_ �Commercial Other Number of living units: --/-- Number of bedrooms_.._.-13 Character of soil to a depth of 3 feet: f r Water table depth SEPTIC TANK A Type/Mfg �' Q - N-L_, Capacity 160 0 � No. Compartments '2-- PKG. TREATMENT PLT. ❑ ! r Method of/Disposal Distance to nearest: Well 00 Foundation "�Property Line LEACHING�LINE Na. & Length of lines 2- -7-�� i t - Totai length/size FILTER BED ❑ Distance to / nearest: Well //0 rc Foundation Z _ property Line J' �•. SEEPAGE PITS .1 IM Depth+ D r _ Size ( 1 O r` Number SUMPS (_l Distance to nearest: -'+Well �O r � J�.W S U)t �_ Foundation = � DO Properly Line f DISPOSAL PONDS L-1\, ;w. 7 S rTY+t f hereby certify that I have prepared this application and that the work ivill--be'-dome in accordance with San Joaquin county ordinances, sta ee l�and' rules and regulations of the Sari Joaquin Local Health Dt%trict. Home owner or Acensedagent's signature certifies the following: "I certify that in the performance of the,work for(which this per is issued shall not employ any person in such manner as'to become subject to workman's compensation laws-of-California.- Contractor,s-ftiring ors mit onssceingsihall not r certifies the following: 'I certify that in the performance,of the work for which this permit is issued, 1 shall employ persons subject to workman's compensre tion laws of;California. , I The-applicant mu f cal! for all required inspections. Complete drawing on reverse side. IF Signed X r Title: Date: FO � NT USE ONLY r ppl ation Accepted by Date �la J/f Area rout )rection by at Final inspection by i Date _�C Additional Comments: _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 f7 Tracy 835-6385 Applicant - Return all copies to: Environmental''Health-�Perrnit/.Services-1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 I FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE EPERMIT'NO, EH 13-21(REV,tiKs) �� /��• ,.��EH 11-26 L/ f�/) 137