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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. i-IAZEL i ON AVE.-,' STOCKTON, CA Telephone (209) 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Addre Cl�a! Citylgl& Lot Size 1Adk_FPM Owner's Name — Address �W€ r "Phone r / �� Z Contractor's Na a ��TLicense No. 35—M/12 _ Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES IISPOSAL FLb. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack © Tracy "fT.ype of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seat5 ' Type of Grout ❑ Irrigation ---Approx.! ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. State Work Done Well Destruction ❑ Well DiameteC Sealing Material [top 501 _ - Depth L---_- - —Filler.MateriaLi BeloW:50-') - - a TYPE OF SEPTIC'WORK: NEW INSTALLATIONi REPAIR/ADDITIONDESTRUCTION 11 (No septic system permitted if public sewer is I j f � ..� "� available within 200 feet.) Installation will rve: Residence A Commercial---%Ather , Number of living 9.s: Number of bedro 3 / A f Character of soil to a depth of 3 feet: +a Water table depth SEPTIC TANK �1' Type/Mfgi �" r 'Capacity 6 OL No. Compartments Z PKG. TREATMENT PLT. ❑ j r ; w Method of Disposal — Distance to nearest' Well Foundation 4 3 ; Property Line ^-�- A t- LEACHING LINE i�Tlo:.& Length of lines ._._��_ �,. L„� ---" Total length/size J r" FILTER BED L11 Distance to nearest: Well 75 1 Foundation Property Line SEEPAGE PITS ;'-!Dist, ,r Deeth 5iz Cumber SUMPS nce to nearest: Well Foundation sQ� Property Line a DISPOSAL PONDS ❑ 1 9 X la Y, 41 � 1 I hereby certify that I have prepared this'application and that the work will be done in accordancre with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Disttict. f t 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 subjectaooworkman's.compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "i ce that in the performa f the work fob which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu I or all required ins i Com to dri rave 6 side. Signed -'Titled 5 Date: tl. EPARTMENT USE ONLY �- Application Accepted by Date Area Jp / � Ak or Grout Inspection byjjY Date l� Final Inspection by & 3 Date Additional Comments: S�v✓A E7' X_e�/1 1.5r_4 r C)d� �71 �' f 1 '7 5 1/3 ❑ Stk 4664MI 13 Lodi 369-3621-�=�----CD-Manteca--823-7404 ❑-Tracy�835-6385-- w--• Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2000, Stk., CA 95201 c FEECK INFO *—TCASH DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMrI^T�"NO. + EH 13.24(REV.10183) /o f� EH 14.26 L 1 1 v 1 L