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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. /V Job Address Z 2 Y �ZA C K TC,�OEF City Lot Size PM Own is Name Address _y 9 Phone i Contractor Address 14,1(15�0 04f1d4 License No.4;92 � Phone r3 7 � 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 PROBLEKII AREA CONSTRUCTION SPECIFICATIONS D Industrial 1:1 Open Bottom ❑ Manteca Dia. of Well ExcaVBtio'n. Dia. of Well Casing © Domestic/Private ❑ Gravel Pack ✓ ❑ Tracy 'Type of Specifications fl Public F Other FI Delta Depth of Grout Seal f 1 Type of Grout I I Irrigation Approx. Depth 1 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State.Work Done , Well Destruction ❑ Well Diameter Sealing Material Itop W1 r -Depth Filler Material IBelow"501 TYPE OF SEPTIC WORK: "NEW INSTALLATION X' REPAIR/ADDITION 1 1 DESTRUCTION l I (No septic system permitted it public sewer is available within 200 feet.) \ Installation will serve: Residence Commercial_ Other r_ , Number of living units: _L_ Number of bedrooms Character of soil to a depth of 3 feet: Thr n.JD ti AV Water table depth SEPTIC TANK ❑ Type/Mfg e-qu.s - Capacity f90' No. Compartments PKG. TREATMENT PLT. ❑ 1=7 ;-`� Method of Disposal Distance to nearest: Well 1-0 Foundation Property Line LEACHING LINE /oNd"'&'tei.wh of lines* Total length/size FILTER SED ❑ Distance to nearest: Well�PFoundation of*7'-Property Line_-.J SEEPAGE PITS I< Depth C91 Size '�3 3 Number Z3 SUMPS ❑ Distance to nearest: Well 9Foundation 520 TAT Property Line DISPOSAL PONDS ❑ 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, and rules and regulations of the San Joaquin Local Health District. I 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-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all equired inspections. Complete drawing on reverse side. - Signed X ` + - —, Title: .�•rc��C Date: � c ?7 1 - FOR PARTMENT USE ONLY f� Application Accepted by Date,��/1 Area Pit Grout Inspection b Date Final Inspection by u Qat�L r Additional Comments: 4,2 L—` r 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-'f104f Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009„Stk.,.CA 95241 - FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE— PERMET*NO. INFO CASH -7 + EH t3-24(REV.I/K 51yy -5 EH 114.26 c./