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` APPLICATION FOR PERMIT 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) LApplication 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. L Joh Address /_3/,I-Nr ZT' -sAGKTOJ✓E kr�b City MAI AYmGA Lot Size 5ZO A<L PM Owner's Name �/1 S F.t/71<,�P�/ C��gddress IYX12. E. MEG LO rJ RD &E iFIPAt Phone 3 ��' L Contractor Jr_/: P &tD 7 Address 7 X. ALI G 1 BGP-T License No. 22 Y7L phone 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION O 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 Lr p trrdustri l ❑ Open Bottom ❑ Manteca Dia.of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications L Fl Public CIOther [1Delta 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 Desi action ❑ Well Diameter Sealing Material (top 501 Depth Filler Material(Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I.1 DESTRUCTION I I (No septic system permitted if public sewer is 6 ./ �''11 REVII itE feet.)_ L Installation vnll serve: Residence/Commercial_ Other�N -ft�l�� ,��,. 6 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: C' L .ate Water table:depth SEPTIC TANK ❑ Type/Mfg e _P 'L— Capacity I'2er! No. Compamnems N PKG. TREATMENT PLT.❑ Method of Disposal 0 LDistance to nearest: Well.!1¢1 Foundation `34 Property Line /04 r LEACHING LINE No. & Length of lines 4,0/ Total length/size '3C' 2/ FILTER BED ❑ Distance to nearest: Well 10 Q r Foundation 4 6 r �Property line L SEEPAGE PIT: 11 ipth .� Size— 3 r Number SUMPS Distance to : Well 1 Z- Foundation '70 Property Line Llrw_axt -3 DISPOSAL PONDS ❑ 1 hereby certify that,l 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 n licensed agents 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 subcontracting 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 comporsa tion laws of Califnnia." The applicant must ca or all requwed inspect' s. Complete drawing on reverse side. / Signed X�� Title:�Yl�� Date: //_z/ �� g FOR PAR USE ONLY - Application Accepted by� � /.�..—� � � Date A a Op Pit or Grout Inspection by Date Final Inspection by Date bw Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3643621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant-Return a0 copies to: Environmental Health Perrtnit/Services 1601 E Hazelton Ave_, P.O. Box 2009, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERM17 NO. INFO