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APPLICATION FOR PERMIT 11 SAN-JOAQUIN LOCAL HEALTH DISTRICT it 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466- 781 PERMIT EXPIRES VYEAR 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address o2-o 7 fo r d� s City Lot Size PM -_W Owner's Name A-yfln I� Address .J = o - ` Contractor � f1.(��r Address PD 1R()rX_... License No. 7 - Phonie TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 'mss ! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ,� t ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.� PROP.LINE E- f. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' h INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a - ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing 1 i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' ? Specifications ,;. ❑ Public 0;Other ❑ Delta Depth of Grout Seal '' Type of Grout' ❑ Irrigation �Approx. Depth 1-1 Eastern Surface Seal Installed by ,w' I Repair Work Done ❑ Type of Pump H.P. State Work.Done Well Destruction EI Well Diameter Sealing Material {top 501 ° 1 Depth Filler Material {Belo 50'4, r C TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI /ADDITION DESTRUCTION I IANo septic system permitted if public sewers ,•• t I� available within 200 feet.) Installation will serve: Residence_ Commercial Other I Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: - �>n ' '� ti'F�]'t7f Water table depth } ` C� G Ca acit o. Compartments QSEPTIC TANK Type/Mfg QJ.L ,n , PKG. TREATMENT PLT. ❑ i ¢ / JMethod of Disposal C Distance to nearest: Well. Foundation Property Line. �1 I 1 �` r , LEACHING LINE ❑ No. & Length of lines "Total length/size- FILTER ength/size FILTER BED ❑ Distance to nearest: Well Foundation' ..Property„L(ne + ..SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation a I Property Line DISPOSAL PONDS ❑ c hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances;state la s, and rules and regulations of the San Joaquin Local Health District. c Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for`which this permit is[ssted, I shall not " employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature i certifies the following:"I certify that in the performance of the work for which this perrriitisis issued,"I'sh`all er661 y,persons subject to'workman's compensa- tion laws of California." ► rt '� . " The applicant must call for all required inspections. Complete drawing on reverse side. s Signed X�1� .+� c'f 1�� Title: l D Id� r Date: FOR DEPARTMENT USE ONLY v_ h ' Date ` !�`�`'µv V4 ' o Application Accepted by t Area Pit or Grout Inspection by I Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 _ „ t J `; Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95201 t 1 `f.. i� �7 t; 1 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASA RECEIVED BY DATE PERMIT`N0. f , +EH 13-24(REV.5/851 is 9rzS«b _ EH 14,28 �j k 1 _