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APPLICATION FOR PERMIT —SAN JOAQUIN LOCAL HEALTH DISTk16T 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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. Al y� l Job Address N r�p,� Cl /-t�,%/� Lot Size PM �� Owner's Name Y7"t �✓� K"- Nddress �'r" � /• ��.SCCY�— Phone � � Contractor Address License No. 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 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 19 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 I I 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 Seating Material (top 501 Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I No septic system permitted if public sewer is ,// available within 200 feet.) Installation will serve: ResiQence— Commercial Other Number of livingunits: SSS�, / Number of bedroom Character of soto a depth of 3 feet: Water table depth / SEPTIC TANK ❑ Type/Mfg 2D'V _ Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ f / Method of Disposal Distance to nearest: Well-F Foundation A0 Property Line of LEACHING LINE ❑ No. & Length of lines —am jotal length/size — y 7 FILTER BED ❑ Distance to nearest: Well 00 Foundation-Rt Property Line SEEPAGE PITS [ I Depth 72Size 2 Number SUMP Ll Distance to nearest: Well 2w: Foundation 12 X/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 California." I mu call for all requ'ed The applic 7i spections. Complete drawing on reverse side. Signed X tv � Title: Date: FOR AN/i��f'"6' i'�,J,r DEPARTMENT USE ONLY Application Accepted by N Da -7Crea Pit or Grout Inspection by Date Final Inspac on by -� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 O 2o-4 8_ t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 D FX O FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO p' ,/� �{ CASH G /( �yyy� p��/q EH t331IREV.tixs /If�✓ ��, (f� / (I �/1 ,/� -� EH It-Ze I! V 666"'