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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091466-6781 PERMIT EXPIRES 7 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.548 for sewage or No.196P for well/purnp and the Rules and Regulations of the San Joaquin Local Health District. l Job Address _6[b . ��G� _ AD Cm,nwy_ Lot Size PM Owner's Name Address f V _ Phone Contractor's Meme ._» 1 1 License No. Phone TYPE OF WELL/PUMP: NEW WELL❑ WELL REPLACEMENT _fl DESTRUCTION D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO:iAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREAa CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private Q Gravel Pack Dia.of Well Casing ❑ Tracy Type of Casing_--. .. ,Specificetions ❑ Public ❑ Other ❑ Delta Depth of Grout Seal W ❑ Irrigation Ty of Grout g —•Jlpprox• Depth .Q Eastern Surface Seal Installed by— Repair Repair Work Done ❑r Type of Pump H,p State Work Done Well Destruction ❑ Well Diameter Searing Material (top 50') Depth Filter Material i8elow 501 d TYPE OF SEPTIC WORK: NEW INSTALLATION L7 REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: .Resldence✓,Commercial____ Other Number of Irving units: Number of bedrooms a Character of soil to a depth of 3 feet: t r Water table depth SEPTIC TANK 0 "Type/Mfg' � F Capac' .� PKG. TREATMENT PLT.Q -f + m' -- No. Compartments Method of Disposal Distance to nearest a VVeN Foundation Property Line 1 LEACHING LINE i ( No.ffi ` - 'Length of ]nes- 14 i Yt `v �of length/s FILTER BED )', ❑ Distance to nearest: Well Foundation .— Property Line SEEPAGE PITS ' ❑ Depth Size ' SUMPS - Number Distance to nearest: Well i,,. �u Foundation Property Line I DISPOSAL PONDS ❑ �" 1 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 employ any person in such manner as to become sub permit Is issued, I shall not } certlfles the following., ��workmen's'compensation laws of Califomila."Contractor's hiring or sub-contracting signature I "I certirfy that in the performanceofthe work for which this pern*is issued;1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all reaW.Fe d inspections. Complete drawing on reversff side - Signed — -• Title:, }� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date - Z/.z Z ."._, Area Pit or Grout Inspection by, 1 ` Data /YF�I ins / f r r pection by— Date 7 Additional Comments: 1 ❑ Stk 466-"l ❑ Lodi 368-'3621 . L]Manteca 823-7104 ❑ Tracy 835-1386 Applicant- Retum all copies to. Environmental-Health Permit/Services 1601 E. Hazelton Ave., P.O. Fiox 2009, Stk., CA 95201 FSO AMOUNT DUE AMOUNT REMnTED CKO RECEIVED BY CASH DATE PERMIT WO.' g »err 1¢24 raLv.tolear EH 1428