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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 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 wellipump and the Rules and Regulations of the San Joaquin Local Health District. s� jgi5 A rC330/ 6 Job Address sCity 2 3 tr1 t 0 D Ir Lot Size ,1 4e PM - _ .� Q� �sy Address o�3a�' Owner's Name_3 Phone.�_�� Contractor l� — Address _12 P S r tW 1e a License No. 3o T - ;;I Phone TYPE OF WELL/ PUMP: NEW WELL ❑ WELL REPLACEMENT ] DESTRUCTION L.1 j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK __- SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ❑ Industrial CI Domestic/ Private M Public t I I IrrHJation Repair Work Done ❑ Well Destruction ❑ I TVPF OF WFi I LJ Open Bottom ❑ Gravel Pack n Other --Approx. Depth Type of Pump Well Diameter Depth _ PROBLEM AREA,. CONSTRUCTION SPECIFICATIONS Ll Manteca Dia. of Well Excavation Dia. of Well Casing U Tracy Typeoof Casing — Specifications I Type of Grout Cl Delta Depth of Grout Seal _- YP t 1 Eastern Surface Seal Installed by - - -- H. P. v 4 State Work Done Sealing Material (top 50') -- Filler Material (Below 50') TYPE OF SFPTIC WORK: NEW INSTALLATION kX REPAIR/ADDITION 1 1 DESTRUCTION I I INo'septic system permitted if public sewer is available within 200 feet.). r Installation will serve: Residence Commercial Other I Number of living units: Number bedrooms _ I j Character of soil to a depth of 3 fast: �-�_ " _ ;^ Water table depth SEPTIC t ANK Vii- Type; Mfg ___ CM _ ._—~Capacity kfu?__ No. Compartments PKG TREATMENT PLT. ❑� r .Method of Disposal 1 Distance to nearest: Well !.`� _Foundation ?®r _Property Line -4 MVPle .r'� LEACHING LINE 34-- No. & Length of lines �i'0 Total length/size a2;�Q t (�P. 1 �,j� f FILTER BED ❑ Distance to nearest: Well 1_l Foundation i __— Property Line_ _. a yr- r SEEPAGE PITS 1 1✓ Depth Size �'�" '�� _ ___— Number -- E SUMPSr Ll Distance to nearest:,' WeHi. _� Foundation Property Line nrconcel PrsNnc - I1 I hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I 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 �folled inspections. Complete drawing on reverse side. Signed X_.. Title: � Date: I,f%/j FOR DEPARTMENT USE ONLY ¢ Application Accepted by r -.✓/ --& Date '' � _ Area I Ir1 Pit or Grout Inspection by Date Final Inspection by � i f Additional Comments: — ! L- Stk 466-6781 Ll Lodi 3693621 ❑Manteca' 823-7104 O Tracy 1335 (3385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a EH 1324 (REV. 1!R5 EH 14 26 FEE AMOUNT DUEAMOUNT REMITTED ASH INFO RECEIVED BY DATE PERMIT"N0. 0.00 �0.6� iib � �� �� `C