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r - ,r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. TMs 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. coem V�NCI kr�� � A Job Address �" w City""` C"W Lot Size 6 " PM Owner's NameJaI)/� -ne bJ Q Ii12 Address 3r 7� Phone 61;gN, sqks ROA A, ctW01Arr-� + ) Contractor's Name License No.o3� Phone TYPE OF WELL/PUMP: DISTANCE TO NEAREST INTENDED USE ❑ Industrial ❑ Domestic/ Private ❑ Public ❑ Irrigation Repair Work Done ❑ Well Destruction ❑ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Gravel Pack ❑ Tracy Type of Casing ❑ Other ❑ Delta Depth of Grout Seal ---Approx. Depth ❑ Eastern Surface Seal Installed by Type of Pump H. P. State Work Done _ Well Diameter Sealing Material (top 50') Depth ,_ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION lyREPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence -7--Commercial — Other 1301511– 14AVIIS Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: T Water table depth SEPTIC TANK Type/Mfg 1� C Capacity-ja1U'f D� No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: I " Q foundation Property Line _ Dia. of Well Casing Specifications Type of Grout LEACHING LINE 11+ No. & Length of lines , FILTER 8E0 L1Distance to nearest: Well Foundation SEEPAGE PITS —;< Depth SUMPS ❑ Distance to nearest: DISPOSAL PONDS ❑ Total length /size Property Line 7,0 .Size _ a;� Number i ..-,l We Foundation /4T Property Line 7� hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Is 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: "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 applic t mu t call all uired inspectio Complete drawing on reverse side. Signed y6d- Title: Date: l© 3% Aw VtJ 'LE I Flo EPA MENT USE ONLY jf <, FOR DC/ Application Accepted by Com✓Date l'0 -3/-may` Area Pit or Grout Inspection by 1N w Date f11 {1'1b Final Inspection by _1Q, ut. +_----- Date C7"3 0 C 3� 3 J AAA - `Ad��rral-tbrrintegts: mstk�1� ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 App scant - Return all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 13-241REV. 10183. EH 14-28 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY CASH DATE PERMIT `NO. L-! S . ©-,_t 4irnr� I r3I c S L>v-l3