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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL ION AVE., STOCKTON, CA Telephone Q09) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED i (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City S Lot Size PM Owner's Name .:577-*F4/e-1fS Address s5tf 01t-96 Phone e a1 Contractor +` • °� � Address 7 M License No. Phone TYPE OF WELLIPUMP: iF NEW WELL ❑ WELL REPLACEMENT CIDESTRUCTION 11 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSALFL„LD.— PROP. LINE FOUNDATION AGRCULT IURE WELL''"''"" OTHER WELL PITS/SUMPS INTENDED USE I,TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom L3 Manteca Dia. of Well Excavation Dia. of Well Casing ❑I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing-----= - Specifications ` nPublic n Other F] Delta L Depth of Grout Seal Type of Grout — I I'Irrigation -Approx. Depth 1 1 EasterSurface Seal Installed by— Re: y r - Repair Work Done..-LD,-Type-of.Pump- .�-H-P-. , State Work Done x Well Destruction ❑ Well Diameter Seating Material (top 501 � r Depth Filler Material (BeV,501 - TYPE OF SEPTIC WORK: NEW INSTALLATIWI�• REPAIR/ADDITION DESTRUCTION i I (No septic "system permitted if public sewer is available within 200 feet.) 14 s . iinstallation will serve: Residence Commercial_ Other _fi s aY Number of living units: /—Number-of-bed rooms a + ✓ . —Water table depth ` Character of soil to a depih of 3 feet: p SEPTIC TANK ❑' ' Type/Mfg .4.'!' Ge Capacity : No' Compartments PKG. TREATMENT PLT. Fl. Method of Disposal t Distance to nearest:, Well 60' Foundation''��' � Property Line !p LEACHING LINE i No. & Length of.lines -'y -,Total length/size z X Z r y � FILTER BED EJ Distance Distance to nearest: Well -- Foundation 7K' � Property Line i i • SEEPAGE PITS W Depth AnC Size _,_ f� _ Number+ t � � SUMPS L� Distance to nearest: Well Id& Foundation 761 .— Property Line 2t9 } 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 cerfifies 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 6f-California."-Contractor's hiring or sub contracting signature certifies the following: "I certify that in the performance of the worts for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." l The applicant must call for all required inspections. Compl to drawing on reverse side. Signed TRW— Date: FOR DEPARTMENT USE ONLY Date Zr 14Area 11 Application Accepted by 4 Grout Inspection ' Dat r final Inspection by Datr� V7 7 t Additional Comments: y 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 L pca�R Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95291 6 � FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT-NO. INFO + EH 13-241HEV.r/nsl .�� ...tia EH 14.28 _ _. �•'©� ..