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L APPLIC`ATIOR" FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA r 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 Joaquir Local Health District. W Job Address //7 -.Grf// J City Lot Size / PM Owner's Name �C� ��icil Address Phone /fw /17f J r 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 FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public ❑ Other n Delta Depth of Grout Seal Type of Grout I I hrigation _..Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 L Depth i Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION t REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Otherp-------------T-p Number of living units:�7<— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK V Type/Mfg r Capacity ?f;,A9 No- Compartments L. PKG. TREATMENT PLT. ❑ . Method of Disposal Distance to nearest: Well Foundation J� Property Line LEACHING LINE No. & Length of lines 5Z El ,1 Tot`al length/size � FILTER BED Distance to nearest: Well_. Foundation�^ Property Line ri y SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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, an, 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 no employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatun certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa tion laws of California" The applicant mu c I for all requ/ired�inspe +t ns.,C late drawing on reverse side. Signed X7iYi rte/ -,G c,6rit Title: Z. Date: 6. IF NT USE ONLY �X � 7 13 Application Accepted by kyi_ �%N.wC4✓.�w'\ Date �-" �— y*Area j Pit or Grout Inspection by Date Final Inspection by� �-L7 Date 10 ` Additional Comments: )5tw ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r! INFO AAMyOOUN�Tt DUE AMOUNT REMITTED /'�C)K�j/`/ RECEIVED BY ]DAF:: PERMIT'NO. 6W . EM M24 IREV.1,95l 1P�. Jfl, d7 Ff4-"YJ �s'C:� �J / �q2q EN 142!