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,J APPLICATION FOR PERMIT 1 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) r 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. 9L1'7a 9' ;�osler' 624• ry� arc. QL -eS PM Job Address r Ci — Lot Size i �a7CD`Dc�O �0 #J Owner's Name "IdW +',�y fie-Q0 Address 9;)- . Phone R t • ' Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PU P INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST---S'EPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED E TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Graver Pack ❑Tracy Type of Casing Specifications 1`1 Pu* 171 Other M Delta Depth of Grout Seal Type of Grout I I t gation —.Approx. Depth I I Eastern Surface Seal Installed by Zpair Work Done ❑ Type of Pump H,P. State Work Done_ 11 Destruction ❑ Well Diameter Sealing Material atop 50'3 Depth Filter Material (Below 501 • TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence )<- Commercial— Other Number of living units: _I Number of bedrooms� '""""".7 Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg + Capacity t No. Compartments. v PKG. TREATMENT PLT, ❑ '` t Method of! Disposal Distance to nearest: Well �� ` Foundation Co Property Line f i I LEACHING LINE { No. & Length of lines Total length/size— FILTER ength/size FILTER BED ❑ Distance to nearest: Well !S12 Foundation ��"- Property Line SEEPAGE PITS t 1 Depth �- �,t � l ~ p (� Size Number .. SUMPS Distance to nearest: Well Foundation Property Line,��"ti c DISPOSAL PONDS ❑ t »� i 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 j employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature I 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 all required inspections. Complete drawing on reverse side. ' / Signed X_OQ2e-F } Jj�_� Title:�m �. Date: r ll r F` FOR DEPARTMENT USE ONLY Application Accepted by __ ( l x6!n, Date ? Area b 9 Pit or Grout Inspection by Date Final Inspection by '-S Date 7 d�� Additional Comments: C'2 cvS• %k -�,r-h�_—%kStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑Tracy 836.6385 s Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFOAMO��U111NT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. FEE. EH 13.24(REV.i/n 5) 0 l ......... /� EH 14-26 L V / 'd