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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE.T ON AVE., STOCKTON, CA _ Telephone (209) 466-6781 I PERMIT EXPIRES 'I 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 GB /�`t/ City 46�7-cw teW Lot Size PM Owner's Name-� l�ia7'T l7 `�� Address Phone Contractor Address 6dVA XL-2v," Modrf°40 License No. Phone TYPE OF WELL/PUMP: 'INEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 4 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 's INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of4Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack O Tracy• Type of Casing Specifications f'l Public f_-1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation .Approx. Depth l I Eastern Surface Seal Installed by ' Repair Work Done ❑ Type of Pump m. ,H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material Melow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATIONN REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is x LL.ti - available within 200 feet.) pQ Installation will serve: Residence/-�'Commercial_ Other v i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: XAdV - AT 3 Water table depth 'p SEPTIC TANK A Type/Mfg _--AayT dre A'r'. Capacity A No. Compartments .Z PKG. TREATMENT PLT. ❑ Method of Dispcla Distance to nearest: Well ��' Foundation S� Property Line LEACHING LINE 2 No. & Length of lines "�`�' ' ..t '' '' T"'. FILTER BED '❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS •1 1 Depth 1' �� Size �� s Number $ �� SUMPS 1A Distance to nearest: Well -ZVI Foundation Property 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 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 became subject to workman's compensation Taws 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. - F Signed X_ Title: Date: 0�,�R DEPARTMENT USE ONLY � ' 7 Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by ^r 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 FFET INFO" - AMOUNT DUE. : A OUNT REMITTED., K H.,�. t RECEIVED BY —. . ...DATE-.-_— PERMIT'NO. �- -- { ♦ EH -24 1REV.!/ii 57 / f J '�y�lQ �i,J X 1 14 EH 14-28