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I APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-67$1 t 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,.... , ;. [I� I Job Address -3193A '� sU ` # y4�, sity Lot Size PM Owner's Name ' Z.i Address Phone q&s3 s .e.� .., Contractorsi__. L&ddress ,. icense_No.. 3 �. phone, �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ;.. SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE I 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 Type of Casing Specifications Vu ❑ Public ❑ Other `E� ❑ Delta Depth of Grout Seal Type of Grout OQ ❑ lrrigation Approx. Depth ❑ Eastern Surface Seal Installed by l}f Repair Workrpondl ❑ Type of Pump H.P. State Work Done. �J Well Destruction f ❑ Well Diameter Sealing Material (top 50') Depth I Filler Material (Below 50')< - TYPE OF SEPTIC WORK: NEW INSTALLATION AIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence` Commercial Actf—Other j Number of living units: Number of bedrooms r Character'of soil to a depth of-3 feet ij �s Water table depth SEPTIC TANK C�Type/Mfg S.� h _�, Canarity`'a �.I.. � ! - - jNo. Compartments PKG. TREATMENT PLT. ❑; -.q r� ( Method of Dis�plosayl-� r Distance'to nearest: Well DO Foundation 1 d Propertq Line f •I LEACHING LINE (dI�M68, Length of lines r -otal length/size I FILTER BED ❑ Distance to nearest: /Nell 007 I i n� _="Foundation 0.. Property Line i r SEEPAGE PITS 9-'Depth ) Size r 13- umber ; SUMk ❑ Distance'tonearest: Well_.._�� Foundation _ Property Line DISPOSAL PONDS Cli ( i 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. 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 E Wifies the following: "l certify that in the performance of the work for which is permit is issued,I shall employ persons subject to workman's compensa- tion of Galifornia." The applic n st all for a requir inspe ions. C mp a ng on revside:'" Sign T- .Date: 4cn 4:& A' _ FOR DEPARTMENT USE ONLYi..t:' r A plication Accepted1 Date U �"�� Area �C Pit r Grout Inspectiof y Date Final"Inspectio ,by Date �� Additional Comments} F ❑ Stk 466-6781 ' ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 Applicant- Return all copies to: Environ-mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTEDCASHRECEIVED BY DATE PERMIT NO + Eli13-241REY.t/65) EH 14-Za I