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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 Ryles and Regulations of the San Joaquin Local Health District. �¢C Job Address City Lot Size 1A PM Owner's Name T/!�11 ".�,' Address ��•b� .C,t �f,/.�i�P l�.p Phone ' Contractor /c/IiGG"2 Address ?6. License No.;2A��_-&9__Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �.. 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 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Sea! Type of Gtout } LJ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 5C REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1% ' available within 200 feet.) (� I Installation will serve: Residence__- Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK T e/Mf ! YP 9 Capacity__ No. Compartments PKG. TREATMENT PLT. ❑ y - 7- Method of Disposal Distance to nearest: Well �lJ� Foundation /d Property Line LEACHING LINE El No. & Length of lines Total-length/size ;?/0 FILTER BED ly Distance to nearest: ,- Well-_4_11&1_00L_�Foundatlon 90 Property.Line SEEPAGE PITS ❑ Depth Size Number - .. SUMPS ❑ Distance to nearest: Well�� Foundation Property Line DISPOSAL PONDS ❑ 4 ,. 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 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 certffies 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." s - s The applicant must call for all Xr uired ' pecti Complete drawing on reverse side. Signed Title: Date: —c3 �" 1+S�,✓ ll -DEPARTMENT USE ONLY t LV Application Accepted by Date 1 Area =R..... f Pit or Grout inspection by Data �- Final Inspection by Date. .` 1' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteb 823-7104 ❑Tr'acy 835-6385 .& Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 55201 FEE1 CK INFO "AMOUNT�DUE AMOUr REMI+rED CASH RECEIVED BY DATE PERMIT'NO. 13.241REV.t/s5) - •1