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qv I APPLICATION FOR PERMIT -, SAN JOAQUIN LOCAL HEALTH DISTRICT 1 Q 1601 E. HAZEL T ON AVE., STOCKTON, CA F Telephone (209) 466-6781 PERMIT EXPIRES 1 YI=QR 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 A Local Health District. A jp�V 49 0- Job Address ►'YS City Lot Size 700 '! PM r Owner's Name +� Address 140 1 1U' CA L-►FeF IV11' e T"' - Phone Contractor = 1: � Addre§'s IJE/-��P-� 5!.6 License No. rY7� Phone 41=43? 2 TYPE OF WELL/PUMP: _ 'NEW WELL-F] WELLREPLACEMENT ❑ _DESTRUCTION 0 PUMP INSTALLATION 1.1 SYSTEM REPAIR ❑ t OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKI - _v. SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS 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 Cl Tracy Type of Casing Specifications t7 Public F] Other `❑ Delta Depth of Grout.Seal r Type of Grout I I Irrigation —Approx..Depth I 1 Eastern k" Surface Seal Installed by r :Repair Work Done ❑ Type of Pump H.P. State Work,Done Well Destruction ❑ Well biameter " Sealing Material Itop 50'1 Depth Filler Material ISelow 50'1 " TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Irl• DESTRUCTION I 1 INo.sepiic system permitted if public sewer is r,r #. e - ' t.f available within 200 feet) Installation'will serve:- Residence l�Commercial_ Other Pu �_j� /SJA Number of living units: / �_Number of bedroorns 2-- r .� Character of soil to a depth of 3 feet: "r ___L-Water table depth SEPTIC TANK Type/Mfg's 7z Capacity L' Cy �'-a 7Capacity 126 C No. Compartments �- PKG. TREATMENT PLT. 0 Method of Disposal � 6 pistanc to nearest: �1Nell Foundation_1 r? Property Line LEACHING LINE No. & Length of lines �" S . Total length/size G FILTER BED ❑ Distance to nearest:' Well As Foundation Property Line � k SEEPAGE PITS I I Depth Size t Alumber � SUMPS ,qi Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ( ; I., :` - - 'r I hereby certify that I have prepared this appllcation arid.that'the work will be dor e;in accordance with San Joaquin county ordinances, state laws, and 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 ss comla ubject to workman' pensation ws 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 must call or all required inspections. qqnplete drawing on reverse side. k Signed X Title: +f Date: .f FOR DEPARTMENT USE ONLY Application Accepted by f' Date 5Z Area Pit or Grout Inspection by i Date Final Inspection by Date fa��'7,� er SGf ens Ile,.Oke Additional Comments: tSicetk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635- nt - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCK H RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24 IREV.1 i n 51 t EH 14-2a