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Ii APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE:, 'STOCKTON, CA Telephone.(209) 466-6781 - i PERMIT EXPIRES 1-YEAR FROWDATE ISSUED I!� _ (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ti +w�""'#a- 4 Job Address t - J '— z , tl _�_ City G Lot Size��_ PM pig - ,} Owner's Name ✓� �L M6)?d Address + Phone 5 zi G Contractor Address License No. Phone r� _TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ � _ DESTRUCTION ❑� j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP. PROP. LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LlIDia. of Well Casing Industrial ❑ Open_Bottom ❑ Manteca Dia. of Well Excavation y I ❑ Domestic/Private ❑ Gravel Pack_,Cl Tracy. Type of Casing _ 1 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation __�I_Approx. Depth ❑ Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump H.P. �' State Work Done z i Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION. EPAIR/ADDITION ❑ DESTRUCTION ❑.(No.septic system permitted if public sewer is V11, / Commercial— Other available within 200 feet.) Ab Residence.V F Installation will serve: Resi l �� i Number of living units: 4 Number of bedrooms t t Character of soil to a depth of 3 feet: _�� YP. r R ' ''--Water table depth No''Compartments SEPTIC TANK ❑. Type/Mfg I V f C�l�n i Capacity- _ PKG. TREATMENT PLT. ❑ Method ofDiospl Distance to nearest: Well Foundation - Property Line i LEACHING LINE ❑ 'No. & Length of lines To)al length/size u Q Q FILTER BED ❑ Distance to nearest: Well 1 Foundation 12 ..__._ Property-'Line _ r1 " SEEPAGE PITS ❑ -Depth Size t Number % I v �,. SUMPS ❑ "Distance to°nearest:-- Well"'^"'"'"" Foundation" ' Property Line DISPOSAL PONDS ❑ '. I hereby certify that I have prepared this application and that the work Yiill be done in,accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Distfict. Home owner or licensed agent's signature certifies the following: "I ce}tify that in the performance of the work for which this permit is issued, I shall not Q ` 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 mu t call for all required inspections. Complete drawing on revere side. , Signed Title: rdA: 1 Date: I FOR DEPARTMENT USE ONLY �f ' N � l Application Accepted by Date _ 7 Area r Pit or Grout inspection by Date Final Inspection by Date Additional Comments: t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 CASH RECEIVED BY DATE PERMITANO. INFO G +EK EN 13-24 t42f (1A 1.1 5) Q .� V7_S5s