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si APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.; STOCKTON, CA Telephone (209) 466-6781. , PERMIT EXPIRES 7 YEAR FROM DATE ISSUED s. (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.= j r: Job Address I City Ll• .- Lot Size Poll Owner's_Name l t-01r� Address SI . one 3�� ?619 r v 1 a , •.,, '. �: s g Q w�Vln Ph ��Contrac4 � �� o �xf Address 1•�.•-y�0� �� r( _License No.' a 'ad(o Phone .3�o$-SIO' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER f, C 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 P� I ❑ Industrial CTO n Bottom ❑ Manteca Dia. of Well Excavation I -- ,'_ _-_ - -.-- --.. ___ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack❑ Tracy �' T s .. �ype of Casing - �.f ._ �'--Specifications I ❑ Public ❑ Other ❑ Delta Depth of,Grout Seal, � s _ Type of Grout O Irrigation � _.�,pprox. De Depth ❑ Eastern '0� 'Sea��'' t \ P Surface Seal Installed by' s Repair Work Done ❑ Type of Pum P H.P. State Work Done Well ❑ Well Diameter - Sealing Material {top 50'} Depth Y r ____JEfiller Material(Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ :REPAIR ADDITION DESTRUCTION ❑ Wo se tic a P System permitted if public sewer is installation witl serve: Residence f available within 200 feet.) ;Com#ercial:_ Other; Number of living units:4_J- Number of edrooms r 3 / Character of soil to a depth of 3 feei: SEPTIC TANK 'f . Water table depth x Type/Mfg.� 1.�P Capacity-J_o7A2� men No. Compartments PKG. TREATMENT PLT. [I + �( / 1 Method of Disposal SJ�T ! Distance toFnearest-� Well dFoundation Property Line O LEACHING LINE No i& Length of lines 0 f €Total length/size /(120 d'o� FILTER BED ';Q Distance to.neares7 Wel! O� r l e -r Foundationa, Property`Line SEEPAGE PITS �❑1 Depth" '�``" 1'f P Size ti Number SUMPS v❑ Distance to nearest: INeI! �' .,. Foundation ; DISPOSAL PONDS -ZEI` Property{Line I hereby certify that I have prepared-this-application-and-that the work will lie done in,accordance with San Joaquin county'ordinances, state laws, and rules and regulations of the Sari'-Joaquin-Local•Health.District. `4 X � _ Home owner or licensef gent's sidnature certifies the followin em to an g: l certify that in the performance of the work for which this permit is issued, I shall not ploy y person in such rr3anner as to become subject to workman's certifies the following: compensation laws of California."Contractor's hiring or sub-contracting signature "I certify that in th performance of the work for'which this permit-is issued,I shall employ persons subject to workman's compensa- tion laws of California." r i The applicant st call for II required inspections. Complete'-drawing ori reverse ide. Signed Tltle:,,F . I Date: !E sr FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by4k� l ti Date ' 4 Final In ,'y+�r--� t:.., ., Inspection by Dat Additional Comments: E }^^�^--�-�'----•?-��---� . ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104. ❑ Tracy 835-6M Applicant Return all copiei to: Environmental'Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 . er FEE AMOUN.T_DUE_„_�.. _AMOUNT. w INFO CASH', RECEIVED BY DATE PERMIT NO. i. .� # + EH 13-24{REV.I/e 5) "^�^� - EH 1426 -. �� • ('J'a .x a. .'t .. 47/ Fr7-