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y 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 FILE COPY (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�iegulations of the San Joaquin Local Health District. Job Address /,/-z -3 CJ ✓,,9&AA1 r JZQ city Lz7,Q/ Lot Size✓ WIR-s-1— PM Owner's Name /1� \,F/f.0/i7s'f� Address b4;1W/;fZ Phone G ` 0/ - Contractor's Name License No. Phone X4L --z V6 0,7 i 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 ❑ Grgvel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Oth;eTZ_ ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth 13 Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') W Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Ll" Number of bedrooms_� 1 Character of soil to a depth of 3 feet: L&IOflo � I�_ D19 Water table depth P SEPTIC TANK Type/Mfg ged Capacity /�C4 No. Compartments ;7— PKG. PKG. TREATMENT PLT. ❑ Method of Disposal L i Distance to nearest: Well J-,A Foundation /V Property Line�dO LEACHING LINE No. & Length of lines / yD Total length/size 2 � FILTER BED ❑ Distance to nearest: Well ATO Foundation ov0 ? Property Line 7^ SEEPAGE PITS Depth L_7 Size r/ Number SUMPS 11Distance to nearest: Well /DA 11 Foundation J-6; 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." Contractors 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 applica t call for all r quuj�l ed In pections. omplete drawing on revers��eyyydddeee'''s IMP Signed X : C/nom-zf Title: Date: FOR DEPARTMENT USE ONLY 4/ Application Accepted by �/✓ ,e.a.� Date Area Pit�Grout Inspection by �>'� �� ' " Da 7�a Final Inspection by d S Additional Comments: ❑ Stk 488-6781 ❑ Lodi 3893821 ❑ Manteca 823.7104 ❑ Tracy 836-0385 Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIY'NO. . EH 11741REV. 10/831 EH 1426 O