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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) 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. 1962 for well/Dump and the Rules and Regulations of the San Joaquin Local Health District.`a (� Job Address / City k dDI Lot Size PM Owner's Name W/4yAn /•/o 1? Address _-574 -ttc Phone-5,66-513 Contractor Fc.m Y/1 G. LUv,7e Address 7 r✓• AY>E�-/3 E/1T As'�6 License No. �Z�Y7G Phone .fK 397/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTT7- DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS hit, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing - ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications \ ("1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout_ \ ` I I Irrigation —Approx. Depth - I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction +❑ Well Diameter Sealing Material(top 50'1 Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION A, DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence Z Commercial_ Other ` Number of living units: Number of bedrooms Character of soil to a de�pth/pt 3 feet: 4'.L/a'Sc n Water table depth SEPTIC TANK flf Type/Mfg ��LrVt7J'.1:T� �"/0?"-- Capacity /Zen No. Compartments Z PKG. TREATMENT PLT.❑ Method of Disposal i r Distance to nearest: Well{60 Foundation /0 Property Line 7-r LEACHING LINE Qr No. 8 Length of lines — 4d r Total length/size r X Z../ r FILTER BED ❑ Distance to nearest: Well 12,4' Foundation 30 t Property Line 7S� SEEPAGE PITS 1 Depth O'S/ Size 3-3 rr Number SUMPS ❑ Distance to nearest: Well '�r Foundation -f0 t Property Line 7-S/ DISPOSAL PONDS ❑ I hereby certify that 1 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 parson 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 for all required inspections Complete drawing on reverse side. Signed-X e Title: /�✓-�/ Data: FOR DEPARTMENT USE ONLY / er/ A plication Accepted by Dater/f.24-(L_ Area �z --yams ��y�`�_�— P' or Grout Inspection by Date 6ltd Inspection by �9vR� Dat;Z J� 11 Additional Comments: O Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 O Tracy 835-6385 Applicant - Return,all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 \ INFO FEE AMf/OUNT DUE AMOUNT REMITTED ASN RECEIVED BY DATE PERMIT'NO. \ EN Ila IREV.�inst UI %�. oO _�6 q7 O_� w/ EN 14]e llh--rrr iyG a C/•'o