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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 5A9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 3+'n�. •95 • I.cJD01) D /gig? City M4A/72—�44 Lot Size PM !'O�m7�/ll S-,C�q My,-,e,; 'e-C, Owner"s Name Address rrlcl _ Phone L34-13"7 Contractor AddressZ.A✓ ADE3,LA-P 7' Aye License No. Zre & Phone S X71 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARESt: SEPTIC TANK SEWER LINES DISPOSAL FLD. 0 0 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 ❑ Tracy Type of Casing Specifications F1 Public f] Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation �.Approx. Depth 1 1 Eastern Surface Seal,lnstalled by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION A DESTRUCTION I 1 INo septic system permitted if public sewer is ' � available within 200 feet.) " Installation will serve: Residence vl Commercial.-_ Other Number of living units: Number of bedrooms-..._ . _ w Character of soil to a depth of 3 feet: 5.4.41D Water table depth SEPTIC: TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ EX IS Method of Disposal Distance to nearest: Well Foundation Property Line —/ "v LEACHING LINE L+f No. & Length of lines 1— 2-0Total length/size 2-0 ' FILTER BED ❑ Distance to nearest: Well �-�+® � Foundation 20 r _ Property Line_....VO r SEEPAGE PITS Jx Depth 10' _Size 4X X 10 r ` Number t SUMPS Distance to nearest: Well 7-- 7 Foundation •2-0 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 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 shalt 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 certifiesthe following: 1 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 required inspections. Complete drawing on reverse side. Signed Title: Date: 3-17-379 ZtF DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection b Pe Y Date Final Inspection by Dater Additional Comments: ❑ Stk 466-6781 ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED /CASH RECEIVED 9Y DATE �PyE�RMtT'N`O. EH 13-24{REV.tiwal .�rG1^1 �y , ! y� /3fz / /� l EH t4-2e VV fit/ �JCJ / J �j/� }