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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT R �I 1601 E. HAZEL T ON 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 Distriiicc. 1 Job Address / '� /�%Gi d' ��cF. City 51_0 4&6!�- Lot Size PM Owner's Name '441 CCA f-'�a>r� Address A2 73 -Tv, fF1%5PY 'A/. Phone Contractor /9 _714 �� t Address 00 1�3Gvc'�{ra /7c11* License No.'YyV`ff41 Thane TYPE OF WELL/PUMP: NEW-WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Ilk DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE=M AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public n Other Cl Delta Depth of Grout Seal Type of Grout __ I I Irrigation _..Approx. Depth I 1 Eastern Surface Seal Installed by �J i Repair Work Done ❑ Type of Pump s """" H.P.: State Work-Done" .I Well Destruction ❑ Well Diameter r Sealing Material (top 50') Depth I F'ille'r Material (Below 50'1 { TYPE OF SEPTIC WORK: NEW INSTALLATIONAI REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other f Number of living units: �_ Numbet of bedrooms Character of soil to a depth of 3 feet: _Gloms► _ Water table depth SEPTIC TANK V Type/Mfg -Gii51-•- { - Capacity 1 add - No. Compartments PKG. TREATMENT PLT,'❑ ' 9 Method of Disposal Distance to nearest: Well'4_011,e"e" r Foundation t s,r Property Line 4 LEACHING LINE rel ,No.'& Length of lines �' u S J Total length/size FILTER BED ❑ Distance to nearest: r Well Foundation Property Line i1 a s A r. SEEPAGE PITS I 1 Depth 140 7 rSize �%�z Number SUMPS jK Distance to nearest: '= Well �9D ' Foundation .Property Line d 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 f 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 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 m t call far all required inspections. Complete drawing on reverse side. ' Signed X_. C� Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Z:�: f Date_ 19 r / f / / Area l Pit or Grout Inspection by r Data Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 r ❑ Manteca 823-7104 N ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.D. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE ? AMOUNTJREMITTED CK RECEIVED BY ! !DATE PE/RMIT'NO. EH 13�24 �� L( +,EH 1428 iREV.i i H 51 L( � ?