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APPLICATION FOR PERMIT r.+ 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) 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 Flegulations of the San Joaquin Local Health District. //N/� Job Address ( 1Z,::2V'Z7 '^n I R t I+O n City Lot Size PM Owner's Name �� Ci Foss Address 5-ryl Pi Phone n Contractor�� L«llrr Address 100 /Zn V,, 1L4 License No. __aT a'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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public (1 Other fl Delta Depth of Grout Seal Type of Grout _. 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 Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence Commercial_ Other Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: 'Cf r y - - -- Water table depth SEPTIC TANK Type/Mfg 194- 1- CIDHc /0¢L Capacity If,0 n No. Compartments PKG. TREATMENT PLT.❑ 1 t Method of Dispysal Distance to nearest: Well II Tin Foundation L n/ Property Line ;4m nd y LEACHING LINE ICY No. 8 Length of lines --AG+ OA tr Total length/size 'TC FILTER BED ❑ Distance to nearest: Well� Foundation r Property Line 76� - SEEPAGE PITS Depth 57 Size-_ Number v s SUMPS Ll Distance to nearest: Well� Foundation 'O Q 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." The applicant must call for all requi/reJ(��Ins�pee/ctions. Complete drawing on reverse side. Signed X 1[LN`�✓ " �[,.CXL!/ Title: �Z,aeo -r Date: FOR DEPARTMENT USE ONLY Application Accepted by ' Date 71 l Area Pit or Grout Inspection by Date 1 t ` Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 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 CK RECEIVED BY DATE PERMIT NO. INFO CASH QI[� '7 • EH 124 IRM ,x5, 70 ,OQ CLQ _ //-16-0 1. �/ -5-YEH 1118