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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 Rules and Regulations of the San Joaquin Local Health District. Job Address E D City S 7A�41/ Lot Sire. .i'I _ PM Owner's Name �E/OVA _J-� 'S �I F Address Phone 9�✓x� Contractor X) 6, Address 29��License No. 7.L—Phone TYPE OF WELL/PUMP-% f NEW-WELL ❑ WELLrREPLACEMENT"0 . DESTRUCTION. ❑ P_UMP INSTALLATION-0 SYSTEM-REPAIR. ❑' OTfiffi'❑ ' DISTANCE TO NEAREST: SEPTIC T A1NK SEWER LINES~_.:..r i !� � � DISPOSAL FLD. PROP. LINE FOUNDATION t AGRICULTURE WELLt _ i 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 P ❑ DomesticlPrivate '❑ Gravel Pack ❑ Tracy Type of Casing� � Specifications ❑ Public - ❑ Other Cj Deltaf Depth of)Grout Seal Type of Grout—.---L__. .—.. E I Irrigation n ��-Approx'Depth t I Eastern Surface Seal;lnstalled by _ _ Repair Work Done ❑ Type of PumpH.P. } State Work Done Well Destruction El,. Well Diameter . �,A _Y I. SealingaMaterial,(top 50') r • Depth 7 Filler Material �.(Below '1 f� I TYPE OF SEPTIC WORK: NEW INSTALLATIONI i REPAIR/ADDITION I DESTRUCTION I 1 INo septic system permitted if public sewer is I i� f available within 200 feet.) ' Installation will serve: Residence Commercial_ Other { �\ S Number of living units: � Number of bedrooms:t'�-" f it Character of soil to a depth of 3 feet: �� 1` Water tabledepth SEPTIC TANK O Type/Mfg A./G t rCapacity--L No. Compartments PKG. TREATMENT PLT. ❑ 3 I Method of Disposal Distancet to nearest: Well Foundation j Property Line LEACHING LINE 9� No. 8 Length of lines 40 Total length/size. 11 7, 1 FILTER BED ❑ Distance to nearest: 4 Well�' .�0�� Foundation )O � Property Line S SEEPAGE PITS. Depth Z0 Size y vZX I fair�ber i � r SUMPS A! Distance to nearest: Well 7s l_ Foundation �' 'Property Line ' ! DISPOSAL PONDS ❑ t I hereby certify that 1 have prepared this application and that the work will Abe 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 th"i following: "rcertify 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 averse side. r Signed X z Date: �- �4 FORiDEPART.MENT USE ONLY g Application Accepted by Date 4 Area �� } e .. (�t � p f Pit or Grout inspection by. Data Final Inspection by Dat y 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 i FEE CK ilk INFO AMOUNT DUE -'`." AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r.EH 13-24/REV.t is 51 . ��y! jf�� {/ J/(? /n l` EH 14-28 70 '" O _ - - ../ _ `tik.' /f�r� U ��r�-�' 7