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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTjopq I 1601 E. HAZELTON AVE., STOCKTON, CA t* Telephone (209) 466-6781 L PERMIT EXPIRES 1-YEAR FROM DATE ISSUED # (Complete in Triplicate) r. i 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. ' 152– P10 L Job Address —. _ ]! C.Y -_ _ City �m(�; � L'at Size PM Owner's Name Gar Address 0' vb frn rqPhone ..." �J !� J�� 1 a / ^7 /} if Contractor._ ?�r�fr� / ur Address � efd 01{C� [JUIC 06 Li _icense No. 6rOSf..7phone_ —031 TYPE OF WELL/PUMP: NEW WELD -WELL-REPLACEMENT ❑ r t_, DEST_RUCTION 1 PUMP INSTALLATION "^� SYSTEM REPAIR ❑ Fri OTHER ❑ - DISTANCE TO NEAREST: SEPTIC TANK, tooI SEWER LINES DISPOSAL FLD_Y i PROP. LINE FOUNDATION' 001 AGRICUL-TURE'WEL•L:- OTHER WELLx . PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 171 Manteca Dia. of Well ExcavationDiaof Well Casing r Domestic/Private Gravel Pack ❑ Tracy Type of Casi'g� ( Specificatian_s F1 Public f Ocher f Delta depth of Grout Seal '�- _�� Type of Gro [ ut �� '.'� rJ I I Irrigation �J'�.-Approx. Depth I I Eastern Surface Seal Installed by�1 l 1 + sem✓:{ �'�=..-mss _ . Repair Work Dane LI..., Type of Pump H.P. i J✓2 � Statee Work Done Well Destruction ❑ Well Diameter i Sealing Material Stop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.) REPAIR/AUDITION €.I DESTRUCTION f I (No septic system permitted if public sewer is _ I �t k ^ 1 t"`, � available within 200 feet.} Installation will serve: Residence_ Commercial_ Others t Number of living units: Number of'bedroom k Character of soil to a depth of 3 feet: ` Water table depth SEPTIC TANK 13' T e/Mf YP 9 I Capacity No. Compartments PKG. TREATMENT PLT. ❑ - Method of Disposal ( F Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size �- FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth 1 Size_ _ Number j �+ SUMPS ❑ Distance to nearest: Well Foundation Property Line } - DISPOSAL PONDS ❑ k I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lawsand rules and regulations of the San Joaquin Local Health Distr ,ict. • 1 Home owner or licensed agents signature certifies the following: I cern that in the " certify 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, 1 shall employ persons subject to workman's compensa- tion laws of Califor {i The applicantym st call for all raqui dins ns. Comp) a drawing on reverse side. 1 Signed X r Z `� Title: r Date: ;JY - -FOR DEPARTMENT USE ONLY Application Accepted by Date 3_17 Are ;?J 7 3 j Pit o . Inspection by Date Final Inspection by pate �IR "369-3621 j / Additional Comments: b� I ❑ Stk 466-6781 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all cHealth Permit/Services 16ol E. Hazelton Ave., P.O. Box 2009, Stk.; CA 95201 FEE AMOUNT DUE AMOUNT REMITTED oelt! RECEIVE(] BY O TE PERMIT'NO. NIN.�F-O/` CASH . EH 13.2 (REV.+/x 51 "r- EH 1028 -013