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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.W for sewage or No. 1862 for well/pump and the Ruie and Regulations of the San Joaquin Local Health District. Job Address (/ �© t/ -'OV �� -K-�`r.r 4,1 - City�� Lot Size� FM_ Owner's Name l �`)� 4.&J M241—M241— Address ,Yw©� Al"'c �`O Phone y tiff License No. 3`j 1 7'Z Phone F Contractor's Name ,g��u _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINER DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done 0 Well Destruction ❑ Well Diameter Sealing Material (top 501 s Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Z availaWe within 200 feet.) Installation will serve: Residence°� Commercial_ Other .t Number of Irving units: Number of be rooms / Character of soil to a depth of 3 feet: - Water table depth $747 / CCCsss SEPTIC TANK 6' Type/Mfg—� t0o"-6- 'V rCapacitvJ2Y& No. Compartments 1� PKG. TREATMENT PLT. ❑ f 1 Method of Disposal Distance to nearest: Well �O Foundation 0 6 Property Line 20 LEACHING LINE e�No. 8 Length of lines Tis Total length/size d FILTER BED Lz3'Distance to��nearest: Well Foundation �2J Property Line 140- B SEEPAGE PITS " Depth [_Size t Number Z--' ,,nz�// SUMPS ❑ Distance to nearest: Well� Foundation O Property Line DISPOSAL PONDS ❑ 1 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 Wmpensation laws of California." Contractor's 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 applicant must call al re lied inspections. Complete drawing on reverse side. QQ// Signed X / Titlej�,�("� Date: JAY /� /� /} FOR DEPARTMENT USE ONLY -/ Application Accepted by / S-io sn�%2/�zal i4_' - y _ Data 2L z y �� Area. / Pit r Grout Inspection by ✓/� Date Final Inspection by�� 47--*-�� Data rt- 2N�y fAi Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6IiM Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CKCASH RECEIVED EIVED BY DATE PERMIT N0. NFO EH 1}M(REV.10/831 1L�tj3 EH 1428 1