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APPLICATION FOR PERMIT t SAN JOAQUIN.LOCAL HEALTH DISTRICTS s 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: Job Address 1pQ `rs [ N / City .571&R% Lot Size PM . -- ppm Address LSAT -- Phone_i/' Owner's Name �°'E�-, ��T-�--� AR License �t�BT License No. L Phone 54* "39`7/ Contractor 8-0 D' W�a. Address Jul,, AR TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I= �lSY,STEM REPAIfl_C1� _ _ -. OTHER Q. . 'PUMP -INSTALLATION- ❑ i I SEWER LINES DISPOSAL FLD._ PROP. LINE f DISTANCE TO NEAREST: SEPTIC TANK _. PITS/SUMPS I Fi I'JNDATION _ _ AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS-- ia. of Well Casing — — - ❑ Industrial El Open Bottom F1 Manteca Dia. of Well Excavation - Type of Casing____!__._ Specifications L1 Dome stic/Private ❑Gravel Pack ❑Tracyi Type of Grout --- (7 Pubtic LI Other ❑ Delta Depth of Grout Seal i. T i; I I Irrigation _-_Approx. Depth I 1 Eastern Surface Seal Installed by - H P State Work Done j} Repair Work Done (.0 Type of Pump _ - Sealing Material ttop 50'? f Wel( Destruction O Well Diameter q I (Below 50'1 Depth Filler Materia '— TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION l I DESTRUCTION l I availableNo 'c system within 200 feet.) if public sewer, is Installation will serve: Residence Commercial.,_.Other Number of living units: —I.. Number of bedrooms `�. art �f,/ I Water tattle depth{: Character of soil toadepth f 3 feet: _.SLA, v: p G Capacity— Method a acity /� No. Compartments' ompartments Z SEPTIC TANK 1kt IYpe/Mfg _.=/�' p s Method of Disposal PKG, TREATMENT PLT. iJ Distance to nearest: Well ��, Foundation _ C •• Pr`operty.Line LEACHING LINE L No. &Length of tines Z ` 1_� -- lotal length/ sizeX 2 + FILTER BED O Distance to nearest: Well /DDS Foundation ��— Property Line Sa t y ' I Number` SEEPAGE I PITS 1'f Depth • — SUMPS Ll Distance to nearest: Well Q_ �— Foundation / Al r -- Property Line DISPOSAL PONDS ❑ hereby certify 6at.l;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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certities'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 law6 of California." i t The applicant must call for all required inspectid Complete drawing on reverse side. c ! �•?�"' Date:— Signed X FOR DEPARTMENT USE ONLY _ Gye^� `�' _ry Date4? Area Application Accepted by / Pit or Grout inspection by __ gate _ Final Inspection by PL t &A, Date Additional Comments: 1V YJ ❑ Stk 466-6781 a Lodi 369-3621 ❑ Manteca' 823-7104 ❑ Tracy 835-6386 Applicant • Return all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 • EH 1324 (nEV. S EH 1438 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT' NO. INFO )069 19 9