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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 = PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (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 Disirict. Job Address Q �S //�� City T4 Al Y A Lot Size PM / IPyf �j SF'.oc �C3£��ou,vr rb:L� /�o.►�e Owner's Name Ae z."_5 619CIZE Address _... ►Rf s�'i.a �� , 1/0'/L'J--'A Phone7_V Z 9(-0 V Contractor 1 N 1?R i S X �n/d SoiVS Address 3!? 0 A1 4/,4,.,,, did License No. 3 M Phone bd 46D TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE ENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM-AR EQ CONSTRUCTIONSPECIFICAT]ONS 4 ❑ Industrial ❑ Open Bottom EJ Manteca Dia. of Well Excavation Dia. of Well Casing I a ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 4 Type of Grout nr. ❑ Irrigation ---!-Approx. Depth Q Eastein� fw b�Surface'Seal Insialleii Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well.Diameter Sealing Material (top 50') Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is � available-within-200-feetJ i Installation will serve: Residence Commercial_ Other old �n k *V6 t de) Number of living units: I I Number of bedrooms —_3 / Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK 211"Type/Mfg n!G Capacity I Z d,41 Gq No. Compartments PKG.'TREATMENT PLT. ❑ r Method of Disposal ~ �P-Distance to nearest: Well = Foundation Property Line LEACHING LINE ❑�No. & Length of lines Total length/size - FILTER BED ❑Distance to nearest: Well '""_Foundation--- Property Line \ 1 SUMPS ❑ Distance-to.nearest:--- Well.—�__ ` r SEEPAGE PITS ❑'Depth Size Number -Foundation----�—_-�--� --Property-Line---•------�--ti---�+� DISPOSAL PONDS ❑ 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 Sari Joaquin Local Health District. I 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 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." s The applican st call or all requir inspections. Complete drawing on reverse side. Signed Title: Date:GO I FOR DEPARTMENT USE ONLY t Application Accepted by We ` G�C 04 G Area 047 " o Pit or Grout Inspection by w e r Final Inspec n by � ��u � Dat AdditionalComments: 1'U it (��l�hhct hlc„i.ltllj f' Yy-v� r W`GlJ1 � ❑ Stk 466-6781 b Lodi 369-3621 ❑ Manteca 823-7104OTracy 835-6385 �� t Applicant- Return all coqips to-EnvifOnmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �z890-Leif o-essa..ar w awrr fv- ./e�fabFEE h INFO AMOUNT DUE _y AMOUNT REMITTED CK # RECEIVED BY DATE PERMIT'N0. .. � �...+ t.T� .3-.. • tet' . a'EH 13.241REV. /a5) 1 l��/ �, b EH 1428 p d