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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. 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. �(J Q2�2 �e 747 Job Address 57 b City Lot Size PM Owner's Name f�-Atl- / gvxddaIT Address ea1�--20 Phone Contractor A, Zoe Address a License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LI 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 © Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public F Other 11 Delta, Depth of Grout Seal Type of Grout _- I I Irrigation _--Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction' ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material {Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION - DESTRUCTION l I Wo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence'e Commercial._ .Other Number of living units: Number of bedrooms Character of soil-to a depth of 3.feet: �'�% jate" '""Water tabled&P0 "" SEPTIC TANK ❑ Type?Nifg Capacity i No. Compartments PKG. TREATMENT PLT. ❑ --Method of Disposal 'Disfante to nearest: Well Foundation Property Line G LEACHING LINE 0 No:.&'Lengih of lines G ' F Total length/size �! �+ FILTER BED Distance to nearest: Wel ��,{ Foundation •A.2 )Cry-- Property Line SEEPAGE PITS Ijl Depth 1 Size' l+' '^"~ s Number r SUMPS ❑' .Distance to nearest: Well -Foundation.` Property Line DISPOSAL PONDS Q I hereby certify that I have prepared this application and that, he work will be done in accordance with,San Joaquin county ordinances' state laws, and rules and regulations of the San Joaquin Local Health District.` �, 1 Home owner or licensed agent's signaturA certifies the following:"I certify that in the performance of the work for which this permit is\issued, I shall not r employ any person in such manner as to become subject to workman's compensation_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." i Y ' The applicant must call for II )red ins tions. Complete drawing on reverse side. } ' 4 Q. Signed X -�L r"j� �'- -' -Title: �.�L-. �* ,date: E FOR DEPARTMENT USE ONLY Application Accepted by Date 3 �b rea l� „ Pit or Grout Inspection by Data .� Final Inspection by ate Additional CommOnts: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 I = ❑ Tracy 835-6385 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK fiECE1VED BY GATE - PERMIT'NO. INFO _ SASH• ",- + EH 13-24 IREV. r7 a/ EH 10-2e 1 C> `�