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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E MAZELTON 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 Regulations of the San Joaquin Local Health District: p Job Address fj z r\J� p (�CI City 1 N Lot Size • M Owners'Name A 1� ` SIL 1/l.�Address'_�.2 �• wNIGHCA-t Cl Ak Phone J r I 3i93 Contractor Address �51� r► 6 2</j�/ 4 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELLREPLACEMENT ❑ 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 O Industrial ❑ Open Bottom''' ❑ Manteca *"Dia.of Wgll Excavation Dia. of Well Casing. t "❑ Domestic/Private ❑ Gravel Pack O.Tracy Type of Casing Specifications ❑ Public -0 Other El Delta Oepi i.of Grout Seal Type of Grout ❑ Irrigation _'Approx. Depth. ❑ Eastern Surface'Seal Installed.blr Repair Work Done. O Type of Pump y.P. State Work Done Well Destruction O Well Diameter Sealing Material(top 562'): Depth Filler Material(Below:50J . TYPE'OF SEPTIC,WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION 1No'septic system•permitted if public sewer is available within 200,feet_) _ .Installation will serve: Residence Z Commercial_ 7Other Number of living units:' ✓) . Number of bedrooms J Character of'soil.to a depth of 3 feet: SeX4 t,y Water table depth SEPTIC TANK ❑. Type/Mfg Pne IA5f Capacity—n No. Compartments PKG.TREATMENT PLT.❑ Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE &00-No. & Length of lines 3. 7 Total length/size .210 FILTER BED. O. Distance to nearest: Well r �D . Founiiation 3_ Property Line SEEPAGE PITS ❑" Depth Size . Number SUMPS ❑ `Distance to nearest-. Well Foundation T Property Line' DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that thework will be done in accordance with San Joaquin county ordinances,.state laws, and rules and I regulations of the'San'Joaquin Local Health District. Home'•owner or-licensed agent's signature.cenifies theJollowing: "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 becorpe 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.pennit is issued,I shall employ persons subject to workman's compensa- tion laws of California." ti ;� The applicant must call:for,all required•in ctions Complete"drawing,pn reverse side. . s tJ -77 Signed X : !`r`' Title: �(,JrVec(; . Date: / ! FOR:DEPARTMENT USE ONLY Application Accepted by `�4. f�� Date Y) Area Pit or'Cirout Inspection by, Date Final Inspection by Date1 =+ Aoditional Comments: Stk.. 466-6781. ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385• Aopliciint-Return all copies to: Environmental Health Pemvt/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952D1 INFO AMOUNT DUE AMOUNT REMITTED RECEIVED.BY" DATE PERMIT NO. > 70 . rEN 13-21(REV.t/9 51- ��. EH 1428 -_-. —