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i - - - I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED 1 (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. 3 Jab Address S� W p�G(I City�VLr tlr- C- Lot Size AeG I'_ PM r , 1l L ( sLSIlO--Address---.qOwner's Nary::- rA - -.Phone. 3- "cro C - LuOL- s��, Contractor's Name l License No. - Phone TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ • DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing CIDomestic/Private o, ❑ Gravel Pack ❑ Tracy rt Type of Casing Specifications ❑ Public ❑ Other Xl Delta= -Depth of Grout Seal Type of Grout 6. ❑ Irrigation t —_Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {tap 501 V Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) r1'1 Installation will serve:' Residence V t Commercial Other 1 Number of living units--I - Number of bedrooms Character of soil to a depth of 3 feet:3 1 Sof Water table depth SEPTIC TANK Type/Mf9 { r 'e_,, Capacity L b [_0L_ No. Compartments PKG. TREATMENT PLT. ❑ T4 _ r - _ -.s; Method of Dispral G Distance to nearest:. Well Foundation Property Line LEACHING LINE No. & Length of-lines 3 - - Total length/size Q FILTER BED C7 Distance to nearest: -Well Foundation Property Line' SEEPAGE PITS ❑ Depth I Size Number (( SUMPS _ ❑ Distance to nearest: 'Well """ .,,—Foundation Property Line DISPOSAL PONDS ❑ T . .f} f 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 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 must call for all reWred inspections.'Corholete diawing on reverse sj&.'' ) Signed % Title: 111 a,' Date: ,_~)-LalO 61 FOR DEPARTMENT USE ONLY Application Accepted by i Gty`— ' --Date Area J3 Pit or Grout Inspection by ! Date Final Inspection by_ ' Nm A1v`i„-_ Date 7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 36.4-36211 ❑ Manteca 823-7104 ❑ Tracy 835-8385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE l AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. i + EH 1324(REV.10/831 EH 14-28