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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. r. - 1 Job Address . ! l �I�t� / r C zfiiCA Ot. ^� Lot Size PM Owner's Name , G rE,E _ Address s�� YE 1.10��E Ph5 r one Contractor (a1 ,�ddress �7 .License No. Y•�?9�.Phone (a TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Ll SYSTEM REPAIR U OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.__ PROP. LINE — — FOUNDATION _ AGRICULTURE WELL OTHER WELL_ PITS/SUMPS — IENDED USE TYPE OF WELL PROBL NTEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack '7 Tracy Type of Casing Specifications G Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I i Irrigation ---Approx. Depth ❑ Easter Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction E Well Diameter Sealing Material(top 50') Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION Ll DESTRUCTION Ll (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_t''/Commercial_ Other Number of living units:—1— Number of bedrooms�_ Character of soil to a depth of 3 feet: fL O!q,M _Water table depth SEPTIC TANK N-�'fypa/Mfg _ C_Ir f— 6 Capacity—LICO— No. Compartments PKG. TREATMENT PLT. fl - Method of Disposal Distance to nearest iWell? u�� Foundation �s�_ Property LineQ� LEACHING LINE �i c. & Length of lines "' Total length/size-- fj FILTER BED C Distance to nearest: Well Foundation �3 (. Property Line sa SEEPAGE PITSf1 Depth /t.' / Sim X10 _ Number , r SUMPS Distance to nearest: � Well-V „Foundation—'—Property Line DISPOSAL PONDS ❑ 4 i I I 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. 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 e y any person in such manner as to become subject to workman's compensation Laws of Califomia."Contractors hiring or sub-contracting signature certifi a following:"'I ertify that in the performance of the work for which this permit is issued,I shall employ persons subject to workmen's compensa tion laws California." . 1 The appiican st all for req ed in ti drawing on reverse so _ ! Signe Tide: r �,f C C1'? l� Date: 3 FO �ARTMENT USE ONLY i Application Accepted y r Date Area ` v Pit or Grout Inspect y Date Final Inspection by ' Data Additional Comments: ❑ Stk 465-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Ll Tracy 835-63% Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO `--) CnASK RECEIVED BY DATE p� pPERMI7 NO./ a EH 1} k 24{REV.i, y /0 .ciu (aV l-2- � ]'L-3—,no EH 14-M l