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n 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) 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 welllpump and the Rules and Regulations of the San Joaquin Local Health Districct` 1 54, Job Address �AS�7R?� /1( City �I�`l7G�lc� Lot Size 2-Ae�� PM + Owner's Name)Szj.,,h- - Address�� SAS -Pt3aY� Phone Contractor 1�in CO, Address . o.ae,�c License No.��_Phone g2&-d- e? TYPE OF WELL/PUMP:-- - -,-.NEW WELL ❑_.__WELL'REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK dD.* SEWER LINES ��@�7f' DISPOSAL FLD.� PROP. LINE �d FOUNDATION � AGRICULTURE WELL OTHER WELL1A57 PITS/SUMPS - ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS « ❑ Industrial ❑ Open Bottom )!�-R/lanteca Dia. of Well Excavation �� Dia. of Well Casing Domestic/PrivateGravel Pack ❑ Tracy Type of Casing P `- b Specifications Cess /�6 h 71 Public ❑ Other 1 Fl Delta Depth of Grout Seal 100 'r Type of Grouthsdlnawjaz!� I I Irrigation /&-..Approx-Depth I 1 Eastern Surface Seal Installed by - - - - Repair Work Dane ❑ Type of Pum'p H.P. State Work Done Well Destruction r ❑ Well Diameter Sealing Material (top 501 Depth t Filler-Material )Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION I I DESTRUCTION I l INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other t Number of living units: f Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 1❑ Type/Mfg f 'Capacity No. Compartments PKG. TREATMENT PLT. ❑ ` Method of Disposal kDistance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance.to nearest: Well Foundation Property Line a r - I SEEPAGE PITS 1 1 Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation 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 stat employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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." t The applicant must call for all requir d inspections. Complete drawing on reverse side. p --11 G/c�C�el-- Date: i Signed X Titfe:FOR DEPARTMENT USE ONLY Application Accepted by Date 4 a .. Area r - Pit orrou Inspection by ~Date /6 Final Inspection Dau''4� 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 I FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFO E +.EH 13-24/REV.r i n sy + O D— EH 14-2e f z k