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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E..HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 7 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 63 /V" 4 QC&,x;- lyfxe City zppx Lot Size # PM Owner's Name Y S/ Q M e�Q16/4Address' -r S Phone `3 0—s-422 `s-422 Contractor_ /C Address - License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME DESTRUCTION ❑ �1 PUMP INSTALLATION ❑ YSTEM R AIR ❑ 3 _A OTHER.� DISTANCE TO NEAREST: SEPTIC TANK SEWER�%;_. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICW L _ OTHERWELL' PITS/SUMPS INTENDED-USE • TYPE OF WELL PROBLEM AREA C RUCTION SPECIFICATIONS` CJ Industrial *❑'Open Bottom —^^G]-Manteca-- of Excavation Dia:of Well Casing -❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casin Specifications ❑ Public ❑ Other ❑ Delta ` 'Depth of Grout al "Type of Grout \ LJ Irrigation �pprox. Depth 11 East n � /Surface Seal Installed by Repair Work Done ❑ Type of Pump �` '� H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 W .' . Depth * t "'°�� _Filler Material (Below 50') a TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_X Commercial Other r Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ff"�Type/Mfg Capacity �7 f7 No. Compartments PKG. TREATMENT PLT. ❑ } Method of Disposal Distance to nearest: Well 60 Foundation Property Line 30 LEACHING LINE E7 N0. & Length of lines �` Total length/size FILTER BED ❑ Distance to nearest: Well Foundation10'rR Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well 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 Iawsr 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 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 m s all for all q 'ed inspections. Complete drawing on reverse side. Signed Title: tC44,n L� - Date: /© /Z FO DEP MENT USE ONLY Application Accept by MDate Area }} 0 Pit or Grout Inspection by Final Inspection by Date` 4< Additional Comments: 43 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO �1 CASH + EH 13-24(REV.I/e 57 -70•U V ;L4-1(P l�y -��.�,p �a EH 1426