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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 I 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. w Job Address b� '`� 4PG City Ae T6—C4at Size PM Owner's Name &1=& Address VI&RRA M, hone NIJN Contractor At.Ai r- �Lt'�k: � ,Address0, 11fT� License No. a Phone TYPE OF WELL/PUMP: NEW WELL ❑* ' WELL REPLACEMENT F1DESTRUCTION ❑ PUMP�INSTALLATION ❑ SYSTEM,REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK SEWER ,LINES DISPOSAL FLD. PROP. LINE FOUNDATION` AGRICULTUR15-WELL OTHER WELL PITS/SUMPS INTENDED USE, TYPE OF WELL,. - PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1:1 Industrial C1 Open Bottom . �❑ Manteca 'Dia. of Well Excavation_ Dia. of Well Casing W 0 Domestic/Private ❑ GraveI'Pack �F ❑ Tracy Type of Casing Specifications C> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal i, Type of Grout--- I rout _I I Irrigation ..Approx"Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done _ Well Destruction a❑ Well Diameter Sealing Material atop 501 Depth Filler'Material.(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I } REPAIR/,ADDITION."- DESTRUCTION I,i,'Mo'septic sXstem permitted if public sewer is r '4 available within 200 feet.) Installation will serve: Residence =Commercial_ otfier �� Number of living units: —cl-I Number..of bedrooms Character of soil to a depth of,3 feet.r _ si4'if.�r�ii'y Water table depth C,� SEPTIC TANK ❑ Type1-Mfg-'°""'"' > ; f -C pacity No. Compartments PKG. TREATMENT PLT. ❑ l .�� Method of Disposal Distance to nearest: Well t' Foundation Property Line ` sC'^" /412 / Total length/size42-0 LEACHING LINE No. & Length of lines Pro l FILTER BED ❑ Distance to`nearest: Well �Foundation � party Ling 3. SEEPAGE PITS i I Depth"o, Size _ Number SUMPS L� Distance to nearest: Well `Foundation Property Line ' DISPOSAL PONDS ❑ s -K 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 certifies the following: "I certify that in thetpteormance of the work for which this permit is issued,,I:-stiait employ persons subject to workman's compensa- tion laws of California." The applicant must all for all required inspections. Complete drawing on reverse-side.— Signed X S Title: _ Date: V�� FOR DEPARTMENT USE ONLY Application Accepted by ".Date rea ii �f c' gData Pit or Grout Inspectipn by Date Final Inspection by Additional Comments: _ r ❑ 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 l _` FEE i AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT*NO. \` INFO -.t EH 13-24 1REV.i%»51 _.., VY-l Y V.♦ - _ ,.-.,' L --i... tv + �/ i -/ EH 14-26