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' - APPLICATION FOR PERMIT .: f SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZEL T ON AVE., STOCKTON, CA t o—r z Telephone (209) 466-6* 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 Rgles and Regulations of the San Joaquin Local Health District. Job Address +� Q 3 r� �0 Vie' 'City i L K �N Lot Size '� �"� I�Cr- �. � � Owner's Name' ��-�" Address -._..... _ _.. _.. _n:. .. Phone Contractor Address 3 S W C icense N,3-=5:I 49,)— Phone 96 a s�i TYPE OF WEL'L/PUMP: NEW-WEL-L❑-'`_—'"""'-WELL REPCAC'EMENT-F1—:-`�"�DESTRI'1CTION"❑-" PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER- ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP:LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ,�...�,.--INTENDED-ISE...._ •4TYIRE� F WELL P-ROBLEM-AREA--CB Tf1dC-T-1ON-SPEC4FIGATIONS-- -- =' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications N " ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout O " Q Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by ► $5 5. Repair Work Done ❑ Type of Pump g H.P ' State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50t) TYPE OF SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION ❑1 DESTRUCTION ❑ (No septic system permitted if public sewer is t available within 200 feet./ ` Installation will serve: Residence commercial— Other f Numbe'r.of living units: Number of bedrooms Character of soil to a depth'-of 3 feet:- r �Q�L _ _. _ .-. _. Water table depth SEPTIC TANK 1R--Type/Mfg C t'1AlC �. � Capacity © 0 No. Compartments/ �-- PKG. TREATMENT PLT. Ll of Disposal Distance to nearest: WelU00 Foundation SO Property Line LEACHING LINE k f�h7o. & Length of lines' " Total length/size FILTER BED �� ❑ Distance to nearest: -_Well's.- Foundation Property Line 74 SEEPAGE PITS lEY6epth s 'SizeF Number f+ IL SUMPS ❑ Distance to nearest... Well. Foundation Property Line } F DISPOSAL PONDS ❑ 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. F, � Home owner or licensed agent's signaturecertifies the following: "I cer*.that in the performance of the work for which this rmit is issued, I shall not employ any person in such manner es 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 Ad work-for which this permit is issued, I shall employ persons subjectto workman's compensa- tion 1 sof Califorri '' .v I The applica m call fo II re uired i' pect' ns,.".. omplete drawingo everse si e. �( Signed I �' Title: bate: 5<�s I FOR DEPA MENT USE ONLY _ re0 Application Accepted by Date A ea Pit or Grout Inspection by �` l/j`��V Date, Final Inspection by Date Additional Comments: * F ❑ Stk 4664781 ❑ 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 9520 z h FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH t + EH13.24(REV.t/s5) .. EH 1428 F N t