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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 District. Job Address ` / „V S . U �l� t31A 9_1P City MA VrT''e•C-4ot Size PM Owner's NameFI-+�i K- 2-6 Z#} 'f s r V K L 04 ' 9,4 . Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS IID Industrial ❑ Open Bottom - ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public n Other 1-1 Delta Depth of Grout Seal Type of Grout _ _ f I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by 1 1 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material )top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION l DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 1L�__ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I&V1 Water table depth SEPTIC TANK 52/Type/Mfg ..� G GOrI r:V eT—'f- Capacity-t-1=0 O No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal LG Pr Distance to nearest: Well _60 IP Foundation 1 Property Line [Q 0 LEACHING LINE ❑ No. & Length of lines Taal length/'size 1 9 Y2. Sr TFi r FILTER BED 011--Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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 J 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."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 m6st call for Il re red inspections. mplate drawing on reverse side. qq p q Signe Title: n.�G Dater / /!CT / OR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date �FFiinal Inspection by ' Date Additional Comments: f. /I�r 1 ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 r I FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. AsTf +.E1 .24(REV.rin51 EHH 114-28 J l I