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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 c� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heiehy made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is fmade 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, Job Address- Owner ddress- �' _ / City �Gr!�! Lot Size w f{� ?M Owner's NameT_.S/S Address e?af, N f f— r7{✓ kawPhone Contractor /1. Address. MZ91 License fVo. �f __- _ Phone - TYPE OF WELL/PUMP: NEW WELL P}- WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ nn DISTANCE TO NEAREST: SEPTIC TANK """ SEWER LINES DISPOSAL FLD.7 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS \� INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing I pp Domestic/Private (Gravel Pack ❑ Tracy Type of Casing 134 dU/-- -6) a`I Specilications f') Public 17 Other4 e11t( Depth of Grout Seal 161( t'1 1=J =�1''!f Type of Grou /�/> Z -_. I t Irrigation -XI/iF Cpprox. Depth te�r� Surface Seal Installed by Repair Work Done Ll Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material (top 50'I Depth f=iller Material (Below 50 _ TYPE OF SEPTIC WORK: NEW INSTALLATION !1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.( pInstallation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. Horne 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 sub-contracting signature certifies the following: "I ertify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- lion laws of California." The appjli a t ca f for all fe uired inspections. Complete drawing on r verse side. , Signed X. '7 Title: Date: lr ~ r / FOR DEPARTMENT USE'O LY Application Accepted fig/ Date rea � Pit or Grout Insp by Data Final lnspeGtion 4 r Datr/ Additional Co ts: ❑ Silk 466-67 ❑ Lodi 369-3621 ❑ Manteca 823-7104 I❑ Tracy 83 -6385 Applicant - Ret s to: Environmental ealth PermiplSerXives l cE. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE A U T REM;}IfTTE'OCASH RECEIVED BY DATE PERMIT NO. EH c3"24 MEv.1/"sr ' lT' ic, FH 14.29 I PLATE 21