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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 a Local Health District. " ' t City Lot Size PM Job Address O*,%ti' !Phone.- Address f�. Owner's Name Q C "a1" +�- •--�-� ' - f°'� License No. Phone - ! Contractor Address 4 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENTS'❑ G.� 0� DESTROCTION ❑ TALLATION If SYSTEM REPAIR LJOTHER El. PUMP INS >� �-+ DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 6�_N t OTHER WELL • PITS/SUMPS li FOUNDATION AGRICU URE ELL __.,� Kati INTENDED USE TYPE OF WELL PR08LEIO'A_REA STRU TION SPECIFICATIONS °Ar I Dia. of Well Casing ED Industrial 0 Open Bottom ❑ M651eca of Weil Excavation rT of Casing Specifications ❑ Domestic/Private ❑ Gravel Pa ck ❑,Tracy ti� Y g Type of Grout (-I Public ❑ Other Cl Delta ept of Grout Seal ! I Irrigation -Approx. Depth I 1 Eastern Suriac Seal tristallad by Repair Work Done ❑ Type of Pump } H`..P. State Work Done— Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') ^ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRJADDITION {.I DESTRUCTION i I avi septic 'system permitted if public sewer is , I !L availablei Within 200 feet.) Installation will serve: Residence Commercial (Other r { r Number of living units: � Number bedroa:�ms if .:w- -T y, . 1�.1YVater table depth V Character of soil to a depth of 3 feet: A, SEPTIC 7AIVK - -- t Capacity �i No-'Compartments .Type/.Mf9— — i .,� PKG. TREATMENT PLT. I, t '� ,Method off Disposal 4 , '- Distance to nearest: k Well AD+Foundation_�L ..— Property Lrne- - ' `l �(� Z'Total length/size LEACHING LINE / No. & Length of.lin'es � c l�J Foundatidn Property Line t FILTER BED Distance to nearest: Well I .- _ t SEEPAGE PITS 1. 1 Depth Number I Size—-- SUMPS ❑ Distance to nearest: Well Foundation4PropertY 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 LacaliHealth'Districti ,; „;� ,w.=s the followin'g::-I_certrfy thak in ncetof the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the performa A employ any person in such manner as to become subject to wSrkman'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'p ermit isoissued, Itshali employ persons subject to workman's compensa- tion laws of California." t The applicant must call for al) required�inspections. Complete drawing on reverse side. - YN F�+��{yah .y/ , —7 Signed Title: �"► � Date: l FOR'DEPARTMENTiUSE ONLY erf 10ate Aida—, — Application Accepted by F y _ _ �9 1 Pit or Grout Inspection by Date ,Final Inspection byl � Date�C�� A ditional Comments: 4Stk 466-6781 O Lodi 369-3621 LlManteca 823-7104 '❑ Tracy 835-63851,/ 1Permit/Services 1601 E. Hazelton Ave., PCO. Bax 2009, Stk., CA 8501 Ap licant - Return all copies to: Environmental Health 1 INFO AMOUNT DUE AMOUNTIREMITTED CK RECEIVED f3Y DATE PERMIT No. t ♦ EH13-24(REV.)/y 51 � 1/ � NJ £H t4-26 /V