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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 r ' PERMIT EXPIRES T 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. n Job Address �' �Za y�C ro V e nck' City STOC-IMP IV Lot Size-fir S PM Owner's Name r l;C h/fek PeNA Address 6/ 7 -5 1#4 C-k TO OV f 9 C Phone r C it;3 =s Contractor A4A�7'hO* -st Address 6002, 9(—v E' bM %`' License No.IYr- 8q/ Phone t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El ab DESTRUCTION ❑ r_ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 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 r r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation. Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'l Public F Other 171Delta Depth of Grout Seal - Type of Grout _ I 1 Irrigation __--Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done — I Well Destruction ❑ Well Diameter Sealing Material atop 50') `* R Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION 1.1 DESTRUCTION i I (No septic stem permitted if _ - p y p public sewer is t available within 200 feet.) f , } Installation will serve: Residence T_ Commercial_ Other Number of living units I Number of bedrooms-_ Character of'soil to a depth of 3 feet: G 4 n Water table depth SEPTIC TANK cwr Type/Mfg Prp ,0S T P+ Capacity .I Cyl D No. Compartments f PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Wellgz Foundation t a Property Line F LEACHING LINE R .No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well I OC � rFou{.ndation.2-4*' r Property Line T^��1 SEEPAGE PITS �"� Depth ;k 5- Size 36 s� ��1 `— Number I i I SUMPS LI Distance to nearest: Well__.1.15" !Foundation CD Property Line �Q DISPOSAL PONDS ❑ I hereby certify that-1.have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stat71aws, and rules and regulations of the San Joaquin Local Health District. Home owneror licensed agent's-signature certifies the following: 'I certify that in the performance of the work for which this permit is issuedno employ any person in such manner as to become subject'to workman's compensation laws of California.'�Contractor's hiring or sub-contractinture" 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=—_8 tion laws of California." 4 11 - � % The applicant mu I call for all required inspections. Complete drawing on reverse side. i 1 Signed X Title: Date_: 4T_JL.>_ 70 9 j DEPARTMENT USE ONLY ��-. I Application Accepted by Date G Area .. 2l�_ �... ; Pit or Grout Inspection by Date � Final InPspection by� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE y i INFO AMOUNT DUE AMOUNT REMITTED O RECEIVED BY DATE PERMIT'NO. +.EH 13-24(REV.t 114 5) r EH 14-26 _1 O� x� /5/ (�