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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.-HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 _PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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 Z& 6J( 1A(12,44W 4h City _S 7-A Lot Size PM Owner's Name Address S.AN10rr ` Phone ~�� Contractor JAJ 0,!7 'A Address A/. A I?!�G.BA9,e9T' License No._0_24!"s1�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 a ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I`l Public ❑ Other ❑ Delta Depth of Grout Seal Type#of.Grout I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 A Depth Filler Material {Below 50'1 �.!` TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.I f1 Installation will serve: Residence Commercial_ Other _ ��pLA LaE rQ�'v[,cc1C3C7� L\\\ Number of living units: Number of bedrooms _ NX Tip NV- 0 Al e->' N Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK fill Type/Mfg .f mL V Mie 7 51-O AC O pacity J 2nZO No. Compartments 4 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well _4 / Foundation Property.Line__._ ! PA A L ir._ Cc1A LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ell Foundation Property Line- SEEPAGE PITS ( I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and that the work will be done in accordance w6h San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. 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 I employ any person in such manner as to become subject to workman's compensation laws of California." Contractoes 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 ail required inspections. __C,om�pi to drawing on reverse ssiidde. Signed X_ 6" 'l A'd'y Title: C-�TJ�� -- Date: —S—9 7— FOR DEPARTMENT USE ONLY + ✓/� � re ff Application Accepted_by ate 2 —�]v6 r.as �. rssSas. Pit or Grout Inspectiony Date Final Inspection by/� �c Additional Comments. ®� _�te Ac .�jC71 ❑ Stk 466-6781 ❑ Lod'+ -3621 ❑ Manteca 823-7104 _C] Tracy-835-6385 AI6�J" Applicant - Retur�� copies to:-Env'ron ental Health P rmit/Services�1 H elt�Ave., P. . Boz 2009, k., A.'9 '. IFEE AMOUNT DUE AMOUNT REMITTED NFO AS ECEIVED BY �ATE PERMITNO. +.EH13-21(REV,tiKsl y� - / f [>•�/-"" - i r` EH 14-28 V I