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s APPLICATION FOR PERMIT -SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (249) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 I 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 _lam_. 9'1?� �._- _�1 C..&rn�fl.- 2-b City I-Q 7 I Lot Size &I'd PM I Owner's Name S7-,i5Y4!r rris_-_ Address 311-3 S. -PAZelc&_ /tb ST f Phone Contractor FL2YD C= - A2410,63 —Address 7 Al- A T License No. 5b2fr3-7Z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El 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 f M Public n Other Cl Delta Depth of Grout Seal Type of Grout 11 I I Irrigation __-Approx. Depth (.1 Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P, State Work Done T Well Destruction ❑ Well Diameter Sealing Material (top 501 ' Depth Filler Material (Below 50') JJ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION i I Wo septic system permitted if public sewer is 1 available within 200 feet:) Installation will serve: Residence Commercial_ Other f Number of living units: __J__ Number of bedrooms F Character of soil to a depth of 3 feet CA-AY 4'0AptpPA�J Water table depth s SEPTIC TANK ❑ Type/Mfg ` r-AIS1-7AJ& Capacity No. Compartments PKG. TREATMENT PLT. ❑ �* Method of Disposal Distance to nearest: Well Foundation Property Line �.k 1 k l LEACHING LINE No. & Length of lines -9_7 40 Total length/size FILTER BED El Distance to nearest: Well ISO Foundation fid' Property Line __30 f SEEPAGE PITS l Depth '~r Size 42-# — Number .3 SUMPS ❑ Distance to nearest: Well Foundation Property Line 3c�, DISPOSAL PONDS ❑ a _ a.1_� 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 IN 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 lawns 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 laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. r Signed X � Title: _-- ~ Date: S — - -w FOR R DEPARTMENT USE ONLY / 1 Application Accepted by Date "r -� Area 1 Pit or Grout Inspection by�� _ Dat Final Inspection by�� F Date 2z 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. ♦.EH1 -26(REV.1/n 51 0 ?�r 1� ,�'. ![d Fq-1`0_371 EH 114-Z$ 4