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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA • Telephone 1209! 466 6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Heaith 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. ,+� ,fob Address o%�__.- -0adds �d� City ,-0_C_,*d4W Lot Size PM t Owner13011"(�H t��f >-N/ Address _Q oeods f�' _ Phone s Name 'r Contrictor /�A/1 �3b f1�/ "t SOIV Address vM � License No.YYf _"J Phone y � TYPE DF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _____ DISPOSAL FLD_i PROP. LINE f FOUNDATION — AGRICULTURE WELL OTHER WELL — PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q Mdustrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of Casing -._. Specifications '1 Public n Other Cl Delta Depth of Grout Seal Type of Grout,--- I rout. _I 1 Irrigation —_Approx. Depth I I Eastern Surface Seal installed by — - --- Repair Work Done Type.of Pump � H.P. —44 State,�iVorkDorre LJ Destruction ❑ Well Diameter Sealing Material Itop50'i Depth-` —=- "" Filler Material'(BW45 f' TYPE OF SEPTIC WORK:' NEW INSTALLATION REPAIR/ADDITION l 1 DESTRUCTION I I INoseptic system•peirhitted if public sewer is t� available within 200 feet.) `1 I Installation will serve: Residence_1 Commercial— Other Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: ��t/t�� DO�Me _ —Water table depth SO I ' SEPTIC TANK 1 1 Type/Mfg Pl'f co,r• Capacity i itto O No. Compartments i PKG. TREATMENT PLT.(7 Method of Disposal__ # I Distance to nearest: Well �0, Foundation �r�__� Property Line �a`Q LEACHING LINE Wr No_ &Length of lines —�j Iry Total length/size �0 FILTER BED C Distance to nearest: Well /OG'� foundation XS' Property Lime x� SEEPAGE PITS 1,1 Depth Size vil F'x /t Number SUMPS I/ Distance to nearest: well�(e0 Foundation lap. Property Line • DISPOSAL PONDS 0 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin Local Health District. Home oYvner`or,ticensed agent's signature certifies the following: "I certify that in the perlomtance 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 mus-candor all required inspections. Complete drawing on revs se side. Signed X Title: _. — Date: R DEP TMENT LWIf ONLY Application Accepted by ^ Date Pit or Grout inspection by -- Date �1 Final Inspection Date Additional Comments: — C Stk 466.6781 ❑ Lodi 369-3621 O Manteca 823.7144 O Tracy 835-6385____1.._, 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 CASH, RECEIVED BY DArE P[RMIY NO. •-EH 13.7 IREV,1i Mti) ER 14-76