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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 r 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 &311 3 5 TC re City i fig c Lot Size.-?fo 6 y/6-,31 PM Owner's Name D A3 d[sem L Address _ ZY E7 7-14 M,22 x< Phone 3 1 4 Contractor's Name 1 4_7 ti License No. �26_ 6_— - ' "'•'""'� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑' DESTRUCTION F1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � INTENDED USE , STYPE_OF WELL"°"�"PRUBCEM'AREA"-'CONSTRUCTION SPECIFICATIONS x ❑ Industrial , ,.,NCI Open Bottom E Manteca t Dia.;ot Well Excavation Dia. of Well Casing` ❑ Domestic/Private `❑ Gravel Pack ❑ Tracy f'� Type of Casing Specifications rte. ❑ Public ❑ Other —❑ Delta _1 Depth of Grout Seal ',Type of Grout ❑ Irrigation _�= 4pprox.lDepth ❑ Eastern Surface Seal Installed by• Repair Work Done ❑ Type of Pump H.PState Work Done Well Destruction ❑ UJ Well Diameter Sealing Material (top 501 Depth _. Filler Material (Below 50'1 TYPE OF SEPTIC WORK:, NEW7NSTAL'LATION Cl' -REPAIRMI)DITION"❑ DESTRUCTION ❑ (No septic system permitted it public sewer is available within.200 feet-.-)- y —Installation-will-serve!—Residence- —Commercial'""-70ther" Number of.living units: �_ Number of bedrooms { -- Character of soil to a depth of,-3-feet:,•-- Fs ' + Wa#er table depth d' SEPTIC TANK 'Eie {Type/.Mfg. "f � � i Capacity-l�— No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well /�d Foundation Property Line t LEACHING LINE No.�-L-eng'th,of lines'•--T3 - yb, �j� Total length/size n� �o_ , 41 FILTER BED "-, ❑ .„Distanc€to"nearest: Well� Foundation �V Property Line"40 SEEPAGE PITS .J" ❑ Depth Size s+ Number SUMPS Distance to nearest.- ,-Well��Fourrdation 1.�ry F�Property Line DISPOSAL PONDS ! Cl „ ,;-1 I j Z 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 k rules and regulations of the San JoaquineLocal Health District. Home owner or licensed agent's signature certifies the following:'7.ceitify that-in the-performance of-the work for which"thls 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 must call for II req u'ed inspections. Complete drawing on reverse Signed _" Title: !� 't� Date: FOR DEPARTMENT USE ONLY Application Accepted by � . - Date Area 7 3 �6- Pit or Grout Inspection by Date Final Inspection by � Date 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 ' 3 FEE j AMOUNT DUEAMOUNT REMITTE _INFO D R,GASH4 -RECEIV.ED_By_-DATE „v PERMn`"NO._. � ,. , - - - + EH13.24{REV.10/831 , ,� Iii • r �..L �S _ EH 14-26 1 - �3..C�/ �S 4F_ ] J