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APPLICATION FOR PERMIT 1,,/ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE_FON 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. 569 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address � �el City Z411--y�` Lot Size A k A. , PM Owner's Name WI_11!4^ If- /.(1a•0_,M&cldress S70I Phone S-9 Z 3 Contractor (/`- ' �l--�c--s Cf-� O Address --Cfr Z&�,Ibl License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA MENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ E TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ ----------FOUNDATION AGRICULTURE WELL OTHER WELL -"-- "PITS/SUMPS INTENDED USE TYPE OF WEL M AREA CONSTRUCTION-SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca 1 Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ cy�� Type of Casing Specifications ("1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _. pprox. Depth I I Eastern Surface Saar Installed by _ Repair Work ❑ Type of Pump H.P. State Work Done Wel estruction ❑ Well Diameter Sealing Material (top 50') ; T Depth Filler Material (Below 501 v , TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION (�' DESTRUCTION I I (No septic system permitted it public sewer is Q> LL available within 200 feet.) Installation will serve: Residence(Commercial_ Other- -STAN c, Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK �q, Type/Mfg _C ,- + t `� Capacity ZZe7d No. Compartments PKG. TREATMENT PLT - Method of Disposal Distance to nearest: Well fa t'.(�Foundation Property Line LEACHING LINE No. & Length of lines Total length/size d FILTER BED ❑ Distance to nearest: Well J 1+1 Foundation Property Line /d'7-i. CCC 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, 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 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 compensa- tion laws of California." The applicant must call fqr all required inspections. Complete drawing on reverse side. Signed X 9- � t2_ w,592,Title: Date: e< y,p FOR DEPARTMENT USE ONLY Application Accepted by `L/ 1(J-S Date — Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 666-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7106 ❑ Tracy 835-6385 Oil Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. . EH 13 24 IaEV.lixsr % EH 14-M