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APPLICATION FOR PERMIT SAN JOA_ QUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA � p Telephone (209)�ip� V 10 '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 Address � tS //C Al,�,Af w City a Lot Size gf l; CPC L4g 5 PM Owner's Name SAC 0� Address �J��Q� -S•_ ,Arz�,�ay Phone Contractor 2 Address -s• d�6 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION-0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ --,OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL'FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS___ cINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + O Industrial ❑ Open Bottom ❑ Manteca ,Dia. of Well Excavation Dia. of Well-Casing ' ❑ Domestic/Private ❑ Gravel Pack i ❑ Tracy,-�'� Type of Casing Specifications f 1 Public 1-1 Other 71 Delta Depth of.Grout:Seal-r ."'`1 Type of Grout 1 1 Irrigation _Approx. Depth� I I Eastern Surfaca Seal Installed by Repair Work Done 0 Type of PUMP H.P. y _State Work Qone-_ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l 3 DESTRUCTION l l INo septic system permitted if public sewer is v available within 200 feet► 1 Installation will serve: Residence_� Commercial___._ Other v Number of living units: Number of bedrooms/ r�/7C! - P °""� f, Water table Character of soil to a depth of 3 feet: / J / depth SEPTIC TANK " X Type/Mfg ' � 4 4,0_&C- //+'' C..acity,G300&76> No. Compartments �f} PKG. TREATMENT PLT. ❑ # - . , '" Method of Disposal Distance to nearest: Well Foundation Property Line /20 40 LEACHING LINE ❑ No. & Length of lines �� _-_ Total length/size 19 11 FILTER BED ❑ Distance toy nearest: Well Foundation Property Line SEEPAGE PITS i I Depth j Size — Number SUMPS Li Distance to nearest: Well. Foundation Property Line M DISPOSAL PONDS ❑ t hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r 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 subjecf-to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance ofthe work for which this permit is issued°I shall employ persons subject to workman's compensa- _ tion laws of California." J The applicant must call for all required inspections. Complete drawing on reverse side. �l1 7 fJ� �. Signed X A7 Title: _. 5, 4 � Rate: 't 1 FOR DEPARTMENT USE ONLY f ! i Application Accepted by i E date lliZ'- -Qy) Area Pit or Grout,Inspection by } Date Final Inspection by, Date /7 r � € Additional Comments: ❑ 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 s i FEE AMOUNT DUE AMOUNT REMITTED fitK 9RECEIVED ey DATE PERMIT'NO. INFO �} 7 EH 13-24IREV 1i N 5) ij� 0 ' ( 7 197_•' EH 14-M v r