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APPLICATION FOR PERMIT ! SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 9(� k Job Address &3 Y IVA, ' 2 City Lo j Lot Size &Ac- PM Owner's Name 1211.c��rw! ! RA OCI-SO Address aCO31 LU w lL Phone 3cf' C/lp so Contractor a9taua��4 4 Address-�Z3I 00514A � License No. 30 Phone,368`..?y33 TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LI DISPOSAL FLO, PROP. LINE FOUNDATION AG51e6iLTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OFWELL PROB AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1`7 Public F Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _-Appr , Depth I 1 Eastern Surface Seal Installed by r Repair Work Done E Type-o Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i REPAIR/ADDITION 1.1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence_ Commercial Other l T� r.� -4 4-a, Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: -S tA1 Ate- Water table depth SEPTIC TANK fl' Type/Mfg 0 J_9L. Capacity l (Go _— No. Compartments PKG. TREATMENT PLT. Q .� Method of Disposal Distance to nearest: Well 400 f Foundation Yo I Property LineaaD f i i LEACHING LINE ,f —No. & Length of lines I 1 Total length/size FILTER BED ❑ Distance to nearest: Well 20 r Foundation I Property Line 200 f ^� I I SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El 1 1 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."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." The applicant must call for al requ d inspections. Complete drawing:on re arse side. Signed X Title: 60�L Date: 7 FOR-DEPARTMENT USE ONLY Application Accepted by Date Z ��g Area iK�7 #Pit or Grout Inspection by" -"y DateI-Inspection by bate�Z Additional Comments: S ❑ 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 AMOUNT DUE AMOUNT REMITTED INFO x� RECEIVED BY DATE PERMIT-NO. + EH 13-29(REV. i x 51 V EH 11-76 * i I