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APPLICAON FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA `e76_ -Telephone (209) 466-6781 PERMIT EXPIRES i YEAR'FROM DATE ISSUED (Con*ete in Triplicate_ ) •� y �r} 4 L. yVl- .., Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described..THs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. ' ' ' W - " '" ' Job Address t City Lot Size PM CZ 7 Owner's Name Address-_--/_76W. - �d Phone ^ Contractor 'T7�'1 O A r ?Address*. License No. Phone60 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EMENT G "DESTRUCTION ❑ - r F. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _.e FOUNDATION "" AGRICULTURE WELL OTHER WELL PITS/SUMPS , INTENDED USE TYPE OF.WELL PROBLEM AREA -CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing 1-1 Domestic/Private ❑ Gravel Pack , ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other - " '❑ Delta ! - Depth of Grout Seal" Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by ,� Repair Work Done ❑ Type of Pump H,P. St to_ Work Done Well Destruction LI Well Diameter Sealing Material (top 50'1+* N f Depth Filler Material Melow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is .� E; r + : available within 200 feet.) Installation will serve: ResidenceCommercial Dther Number of living units: Number of bed r s / 04 {� Character of soil to a depth of 3 feet: Water table depth POO i SEPTIC TANK t A—Type/Mfg Capacity� No. Compartments k rPKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:. Well Foundation Property Line r LEACHING LINE— . �+ No. & Length of lines ''� L"T"Total length/size 70 it i FILTER BED ] Distance to nearest: Well�� Foundation Property.Line 7�— SEEPAGE PITS Depth �s Size �s Number SUMPS Distance to nearest: .,Well ovim.-._.— Foundation 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 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 Ca' rnia." t +! t i � The al mu call Dgre�.irecl inspections. Complete drawing on reyee side. ' t Signed Title:` Date: d��FOR DEPARTMENT USE ONLY Application Accepted by -" Date Area " Pit or Grout Inspection"by Date Final Inspection by Date rdditional Comments: # Stk 466-6781 ❑ Lodi 369-3621 rO 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 INFO FEE AMOUNT DUE, AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. a.a EH 13-24IREV.-5./e 51 L ` tA EH 14-28 1