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�r r` a APPLICATION FOR PERMIT SAN JOAQU.IN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED o (Complete in Triplicate) f� 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 &ff,.,,,RA4,,,,rq4Ci, Lot Size PM Owner's Name ��Q `r" ' ATfHress� J /� Z Contractor Address License Nof Phone t 11 i TYPE OF W LL/ MP: NEW WELL ❑ WELL REPLACEM NT © DESTRUCTION ! PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE s FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE` TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ industrial n a '.❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f"1 Public Ll Other F F1 Delta Depth of Grout Seal Type of Grout l 1 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 (top 501 pp Depth Filler Material (Below 501 - 3 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAI ADDITION I 1 DESTRUCTION 1J INo septic:system permitted if public sewer is r r. y avaijable_within'200 feet.) Installation will serve: Residence Commercial_ Other } ! Number of living units: Number of bedrooms ° ` _#..'M►" +': '�, #� .i Character-of-soil-to a-depth-of-3-feet: —4el 9Z a A 01 Water table depth SEPTIC TANK 0 Type/Mfg Capacity N7A Wo. Compartments . i I PKG. TREATMENT PLT. ❑ ` " , Method i sal Distance to nearest: Wekl Foundation Property Line "at LEACHING'UNE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line .. SEEPAGE PITS I i Depth° Size Number UMP 0 Distance yto_nearest: Well Foundation Property Line DISPOSAL PONDS _El- l• I-I 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' a ° rules and regulations of the San Joaquin Local Health Di%trict. " Home owher or;l censed 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 ah such manner as to become subject-to workman's compensation laws of California.' Contractor's hiring or sub-contracting signature t 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." r`• a .+ The applicant us f II req ed inspections. mplete drawing on verse side. C Signed X Title: Date: OR DEPARTMENT USE ONLY ' Application Accepted by .' Date ` Area i i+ Pit or Grout Inspection by Date F- al Inspection by Date !� P V Additional Comments: I 2 r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20W, Stk., CA 95201 i FEE i i INFO AMOUNT DUE AMOUNT REMITTED CC SH RECEIVED BY DATE PERMIT IVO. ...E .t3-24IREV..,,.n.$)-....-.-.,... 14-2e