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i APPLICATION FOR PERMIT, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 F 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 7a�� City AA4AI& Lot Size- b PM ! L, Owner's Name i� r�d Address Tus Phone 1 J i Contractor Address ,747 I 'cense No.30Y2W Phane ��U TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t 1 PUMP INSTALLATION g- SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t 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 I 1-l'-public n Other n Delta Depth of Grout Seal Type of Grout I I llrrigation --Approx. Depth ! I Eastern Surface Seal Installed by ' - I Repair Work Done' ❑ Type of Pump H.P. State Work Done_ t WellDestruction} , ❑ Wel! Diameter Sealing Material 'top 501 Depth Filler Material [Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Or REPAIRIADDITION l 1 DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet./ e I nstallation will serve: Residence be" Commercial Other i Number of living units: t Number of bedrooms `'f .Character of soil to a depth of 3 feet: CSWater table depth d I' `SEPTIC TANK [Ar Type/Mfg Capacity—� No. Compartments CoNe r ' "PKG. TREATMENT PLT. ❑ � Method of Disposal - Distance to nearest: Well Foundation ,t r Property Line/1040 LEACHING LINE Cf No. & Leng th of lines t C �,TotaE len9 thlsize O --� FILTER BED ❑ Distance to nearest: WellFoundation Property Line -._ ✓o �' k SEEPAGE PITS IL✓Depth Q ZS� ��Size Number 2 1 SUMPS Ll Distance to nearest: Well P70 ! Foundations_._ Property Line--- DISPOSAL PONDS ❑ I hereby certify that I have prepared-this application and,that the work will.b6done in.accordance with San Joaquin county.ordinances, state laws, and rules and regulations of the San Joaquiri Local Health District. Holme owner or licensed agent's signature certifies the 616wng�I certify that,in the performance of the work for which this permit is issued, I shalt not employ any person in such manner as to become subject to workman's comparisation laws of California."Contractor's hiring or sub-contracting signature t ceAifies 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 Califo' 'n_ia." t t t I The applicant must call ifor all r quired inspections. Complete drawing on reverse side. I I — I r" a" Signed X TitE;�; "v Date: f � 1 FOR DEPARTMENT USE ONLY Application Accepted by F Date '~ +? Area ; I � I t-or Grout Inspection by a a Ki al inspection by Date Additional Comments: t ❑�tk 466-6781 13 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 95201 f FEE m AMOUNT DUE AMOUNT REMITTED ,CASH!4 RECEIVED BY DATE PERMIT'NO. INFO -�h) Y t EH 13-24 1REV.1/n 51 A), . t y p EH 74-28