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Ior�Q APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT J 1601 E. HAZE T ON AVE., STOCKTON, CA J Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (Complete in Triplicate) T 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 incompliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wall/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address — 7 � 11/�} City Lot Size = PM 7 /Z7WZe0�9 Phone Address Owner's Name_ Cv2Ts Contractor dress I`le'� License No. �O�0--// Phone TYPE OF WELL/PUMP: --NEW ValE L ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION F] SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS FOUNDATIONS y ED USE V' TYP S OF WELL ? PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1` I� INTEND y Dia. of Well Casing ❑ Industrial ✓ ❑�ra pe Bottom I ❑ Manteca Dia. of Well Excavation . Type of Casing Specifications ❑ Domestic/Private v' ❑ I Packs ❑ Tracy Yp g Type of Grout ❑ Public ❑ th lr ❑ Delta Depth of Grout Seal ❑ Irrigation p1? X. Sh ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done I Sealing Material (top 50'} Well Destruction ❑ Well Dia r 9 Filler Material (Below 501 (No set TYPE OF SEPTIC WORKi�NEW.CINSTALLATION El .REPAIR/ADDITION ❑ DESTRUCTION ❑ availableiwi hin 200 feet.) if public sewer is Installation will serve: ResidenceCo�mercial—q"_ �O'ther Number of living units: Number of&drooms - �d 9 �Q CG¢� Water table depth \( Character of soil to a depth of 3 feet: SEPTIC TANK Type/Mfg = �"� ('pr/tlltT£ Capacity No. Compartments /7�y Methodof Disposal ` PKG. TREATMENT PLT. ❑ 1 i �' , Distance to�+aerest Well Foundation ! r Property Line; I Total length/size j LEACHING LINE �No. & Length of lines_Z ! - k� f FILTER BED ❑ Distance to nearest: Well 75 S'Feundati62 — Property bne F j � f ; SEEPAGE PITS Depth (� 7 Size 3 Number SUMPSt 0 Foundation i Property Line ❑ Distance to nearest: � Well�_ j DISPOSAL PONDS ❑ I hereby certify that I have prepared this applicationand that the work will be done in accordance with San Joaquin county ordinances, state laws, an 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." F 1, The applicant must c qui'ddris s. Complete drawing on reverse side. 9 d�w I. Title: _ �� Date: f Signed - I FO P RTMENT USE ONLY a Q Date `� U Area Application Accepted by f -Pit"or Grout inspection by. pate 9=10Final inspection by T Date t Additional Comments: ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE !CKRECEIVED BY DATE PERMIT'NO. INFOLTAMOUNT DUE AMOUNT REMITTED +EH 13-24IREV.i/851 d`4'b EH 1428