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J, 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 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address city A Lot Size PM aYG'S PM Owner's Name Address 3eJ 4104v ,t�CA;Ci7phone Contractor 0, /041 �N Address License No, phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' �� !' 4bISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS 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 f I ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ! ❑ Delta ' Depth of--Grout Seal Type of Grout ❑ Irrigation _Approx. Depth ❑ Eastern ' Surface teal Installed by, Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 C. 'n Depth Filler Material (Below 50') ''` s r TYPE OF SEPTIC WORK: NEW INSTALLATION 6d REPAIR/ADDITION ❑ DESTRUCTION ❑ fNo septic system permitted if public sewer is Y – Installation will serve: Residence— Commercial— Other H7b(P)Z 40"Or r available within 200-feet.) Number of living units:I Number of bedrooms 3 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK P Type/Mfg C Cn►sT CA��,r Capacity f X oto No. Compartments PKG. TREATMENT PLT. ❑ ^^–'�- Method'of Disposal ' ' Distance to nearest: Well O 'u AO' �/ Foundation Property Line LEACHING LINE M No. & Length of lines 3 "' y0 Total length/size /O ' FILTER BED ❑ Distance to nearest: Well AA OFoundation x vo Property Line SEEPAGE PITS ❑ Depth Size Number r SUMPS ❑ Distance to nearest: Well Foundation-T--^�– -�-�–property Line' 4 DISPOSAL PONDS ❑ ��.- t°.L: ._ I hereby certify that I have prepared this application and that the work will be don4–F&accoi`i ance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. a Home owner or licensed agent's signature certifies the followin Ij ` employ an --- g�..`.`I certify,`�hat�fn-the performance of the work for which this permit is issued, 1 shall not p y y person in such manner as to become subject to workman's compensetltal8 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." �` The applicant mus call for all required inspections.-Complete-drawing on reverse side. e� Signed a Title: Dated G:f.r FOR DEPARTMENT USE ONLY Application Accepted by Date I Lrea Pit or Grout Inspection by Date Final Inspection by Additional Comments: /Yl p 6 4, J . z ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M ~ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 901 FEE AMOUNT DUE AMOUNT REMITTED CK ' r INFO CASH RECEIVED BY DATEPERMIT"NO. + EH 1324[REV.F/a57 _7�` 6�� EH 1426 C! ( 1 ! eo i