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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466.67$1 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 �f s o� i✓/2G/L Owner's Name DLA1�' L._%S Address City S?X�►/Lot Size `s )r 13.,- PM Phone 93/--2-0 J G __.. Contractor F7L_&YJD f= :Address _7 41. /%jE License No. LSJ-%�_- Phone TYPE OF WELL/PUMP: DISTANCE TO NEAREST INTENDED USE O Industrial O Domestic/ Private I'l Public I I Irrigation Repair Work Done Well Destruction O NEW WELL 0, WELL REPLACEMENT EJ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER O SEPTIC TANK ._ - SEWER LINES- DISPOSAL FLD.___�PROP. LINE _ FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Open Bottom ❑ Gravel Pack F1 Other --Approx. Depth Type of Pump Well Diameter Depth ❑ Manteca Dia. of Well Excavation ❑ Tracy Type of Casing .F Delta Depth of Grout Seal I I Eastern Surface Seal Installed by------- H.P. y__-_-_H.P. State Work Done Sealing Material (top 501 Filler Material (Below 50') Dia. of Well Casing Specifications Type of Grout _ TYPE OF SEPTIC WORK: NEW INSTALLATION I:i REPAIR/ADDITION DESI RUCTION i I (No Septic system perinrtted'il ptiblicsewer is / available within 200 feet. / Installation will serve: Residence "� Commercial _ Othei Number of living units: �— Number of bedrooms ' Character of soil to a depth of 3 feet: _ C L i4 5/-'�` Water table depth SEPTIC TANK U Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal _ Distance to nearest: Well _ Foundation _ - _ - Property Line LEACHING LINE No. Jar Length of lines o-� r Total length/size g� f FILTER BED Cl Distance to nearest: Well S -Q t Foundation .2y Foundation Property Line SEEPAGE PITS lel' Ue th �� r Size �� " Number SUMPS L1 Distance to nearest: ----Well -1 Up Foundation 71?. _ Property Line S z 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 Di§trict. 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 must call for all required inspections. Complete drawing on reverse side. Signed X�,�.G..' .. = Title: 1 _.._ Date: FOR DEPARTMENT USE ONLY e Application Accepted by - ��.�*-�� Date �� Area it r Grout Inspection by Date 6 Z Final Inspection by. Data Date 6' Additional Comments: Ll Stk 466-6781 D Lodi --369=3621--~~ -tD Manteca ---823 7104 -C] Tracy 835.6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Slk., CA 95201 Nt ..EN 13-241AEV.Iiws £H 14-29 FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. �0 1� Cs� �1� �► r I