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r. APPLICATION FOR PERMIT �I 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.54.4 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, Job Address � ,1�.tF, City Lot Sizd � PM /} Owner's Name _t�GCZL,,_ Address d �/ � =r Phone Contractor ��" L�__ _ Address License Not -7 Phone- v 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 n Other F1 Delta Depth of Grout Seal Type of Grout I 1 Irrigation —Approx. Depth I ) Eastern Surface Seal Installed by AV '\ Repair Work Done ❑ Type of Pump H.P. State Work Done 1�' Well Destruction ❑ Well Diameter Sealing Material (top 501 q -,_,A' Depth Filler Material (Below 50') d _ TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence C'�_COmmercial— Other �a C Pte, 5—o Number of living units: _�_ Number of bedrooms 2— �T .Character of soil to a depth of 3 feet: L �r- f Water table depth SEPTIC TANK Cr�fype/Mfg ►��, Capacity No. Compartments �— PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well , / Foundafion=!Z-6 Property Line 1 1. LEACHING LINE 6Y_No. & Length of lines _ '~ 9 Total length/size FILTER BED ❑ Distance to nearest: Well Y-2-0 r Souridation Property Line SEEPAGE PITS f-r--Depth 4;7 F Size rr _ Number SUMPS Cl Distance to nearest: Welj- - fJ Foundation O ' Property Line DISPOSAL-PONDS Cl I hereby certify that-I have prepared this application and that thBwirork will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Distiict. I k Home owner or licensed agent's signature certifies the following-t"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 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 requi%d in pections. Complete drawing on reverse side. Signed X Title: f.-�4- Date: i FOR DEPARTMENT USE~ONLY Application Accepted by orDate J �y- Area q /F iC or Grout Inspection by t15 9Final Inspection by Date f Additional Comments: ❑ Stk 466-8781•: .----p-6e6-369-3621 ❑ Manteca -823-7104— - 0 Tracy 835-6365 — — --- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E—Haielton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT ITT p� INFO CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.I i H 51 EH 14.26