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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 Dis rict. City ,7 A✓ Lot Size TAS PM Job Address ' Ph e Address S. TA Gi�?D�CJE 2 .n -�` G Owner's Name_4 . '- eft `• E T �� License No. � 7 -Phone Contractor- p—+�� Address TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ k :I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C3 DISTANCE TO NEAREST;r_SEPTIC TANK_ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED4�6SE -TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing r ❑ Industrial ' ❑ Open Bottom' ❑ Manteca Dia. of Well Excavation 1 ! El - Type of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack Type of Grout - (l Public n Other Cl Delta Depth of Grout Seal r -I—, •"�A"-pox Depth i I Eastern Surface Seal Installed by I I Irrigation —_- pP Repair Work done ❑ Type of Pump H P State Work Done— Sealing Material Itop 50'1 t Well Destruction ❑ Well Diameter 9 iii' Depth Filler Material (Below 501 6 TYPE OF SEPTIC WORK: NEW INSTALLATION qq REPAIRIADDITION l 1 DESTRUCTION l I (No septic s i'iern 200 feet)permitted if public sewer is available Installation ill serve: Residence✓ Commercial— Other ' Number of living units: ,Nurnber of bedrooms w a LR y Water tabledepthj n Character of soil to a depth of 3 feet: Z j/) '(' L p No. Compartments SEPTIC TANK L3-. Type/Mfg Capacity ri 2-p _ CYT- -- PKG. TREATMENT PLT. ❑ i t`- ` , Method of Disposal Distance to nearest: ;,Well- !ql� Foundation jQ Property Line 3&O LEACHING LINE o. & Length of lines �'" f Total length/size FILTER BEI) Distance to nearest: Well*_ GI Foundation Property Line 2. SEEPAGE PITS I Depth a _Size_._-.. n Q Number �� ` 3 4D ' Distance to neares 't: Well �0O Foundation � SUMPS L1 Property Line DISPOSAL`PONDS ❑ '�_ ` ' % - � I hereby certify that I.have prepared,this application and that the work-will in accordance with San Joaquin.county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. "- L Home owner!]r licensed agent's signature certifies the following:-1.1-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." Contractors 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 Wall required-inspections. Complete drawing on reverse side.+ _��V_. �_- _ ... .� _- '4- _ �_ J Date: Z "*a Signed X Title: ? FOR DEPARTMENT USE ONLi I ', _ ' ' Area T Application Accepted by Date 3 � 27 �9 Date~ Final'Inspection by Date Pit or-Grout inspection by _ Additional Comments: M f� ❑ Stk 466 16781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy'835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,-f'.O..:Box=2009, Stk.,.CA-95201 FEEE;AMOUNTUE AMOUNT REMITTED CASH RECEIVED.BY DATE PERMIT NO. ,INFO f, EH 13-24 INEV.t/n 51 ' EH 14-2e r _