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APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICTSCANNED " 1601f. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT.�EX.PIRES 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 L'S 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. t vdce Job Address ! / b 1d1 11� City Ta'� Lot Size . PM I Owner's Name C _ p- Address F6_&2 -1/ /41rz,&69 Phone Contractor A, ,�-LJ_ � Address`B 61 lf�f All IdA License Phone TYPE OF WELL/PUMP; NEW WELL ❑; WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION I 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 FI Public Cl Other n Delta Depth of Grout Seal Type of Grout _ T_ f 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump- H.P. State Work Done Well Destruction ❑ Well Diameter ? Sealing Material Stop 501 Depth i Filler Material {Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 " REPAIR/ADDITIONO DESTRUCTION l I (No septic system permitted if public sewer is J available within 200 feet.) Installation will serve: Residence Commefcial other s9/I+fjy� Number of living units: .I Number of 6eooms Character of soil to a depth of 3'feet: eA Water table depth SEPTIC TANK . ❑ Type/Mfg /_1 Capacity- apacity Oe/ C1iP 444o. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest. WellCZ OE foundation Property/ Property Line,l LEACHING LINE f ( No. & Length of lines Total length/size r! FILTER BED ❑ Distance to hOarest: Well 422 Foundation�� Property Line AFT` i . SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to.nearest- Well-..,.___.__� Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this app t'nation 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 HeaI6 Di§trict. ... Home owner or licensed agent's signature certifies the following: "I certify that:in the perfotmance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subiect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that inthe perfotmanca of the work for which this permit is issued, I Shall emdloy persons subject to workman's compensa- tion laws of California." The applicant must call fol,00d]; requ'red inspections. Complete drawing on reverge side. Signed K Title: .../ Date: / FOR DEPARTMENT USE ONLY l _ Application Accepted by Date �i Area 2 JS Pit or Grout inspection by Date Final Inspection by Date,�`� -- Additional Comments: ❑ 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 95201FEE . INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE �TPERMIT'NO. r (REV.r/ns) EH 11.28 I