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APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT j 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.TNs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. A Job Address _ . ► Cit 1s1, N Lpotr�Size_ PM Owner's Name _1 _�r'L��1 L!/_.�'�c�_. Address Phone _ 9 Contractor_��1<_ GJC�e—.Address / ��1 -License No.V�ff_Phone TYPE OF WELL/PUMP: NEW WELL Wt (L REPLACEMENT L: DESTRUCTION L I PUMP INSTALLATION : ' SYSTEM REPAIR r OTHER Ll 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 Industrial Open Bottom Manteca Dia. of Well Excavation Dia.of Well Casing i Domestic/Private Gravel Pack Tracy Type of Casing_ Specification/s/ II Public Other Delta Depth of Grout Seal Type of Gra _ C; Irrigation _Approx. Depth Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done r Well Destruction Well Diameter Sealing Material(top 50'1 Depth_-__ Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION : REPAIR/ADDITION1l DESTRUCTION i (No septic system permitted if public sewer is c, /, available within 200 feet.) 1 Installation will Iserve: Residence /<':" Commercial-. Other Number of living units: . /_ Number of bedrooms__3 Character of soil to a depth of 3 Tec,. /�J!/D �G�_/~L__- _...._--_Water table depth— y-. SEPTIC IANK I ' Type/Mfg ..-_ _. .__ �-._-_-_.. Capacity__ No. Compartments PKG.TREATMENT PLT.! Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. &Length of lines _ __ ��-�� - Total length/size FILTER BED Distance to nearest. Well_ TJ94'nd.ti.n__:?e1tF Property Line SEEPAGF PITS Depth ____--._.Size -___--..-_--____. Number SUMPS Distance to nearest: Well ._ _ Foundation Property Line DISPOSAL PONDS I ~ I hereby Lertify tnat I have prepared:his application and that the work will he done in accordance with San Joaquin county ordinances,state laws,and rules and regula!ions 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, !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 i„the performance of the work for which this permit is issued.I shall employ persons subject to workman's compensa- .ion laws of California." The applicant must call for yll re ms cons. Complete drawing on reverse side. moi. �� Date: S c / Signed X -"'- �i�"_� -— Title: -_.-1 �-��f�— ----- Date: zl Y a FOR DEPARTMENT USE ONLY Application Aurptc;l by !"�G -.------ Date_ .�." Area---�- Pit or Grout Inspection by ---_... -- Date -- --- Final Inspection byi / Date Additional Comments- - : Stk 466-6781 is Lodi 3693621 L, Manteca 823.7104 _:Trcy 8:5-63e5 Applicant - Return all copies to: Environmental Health Permit ISet-.ices 1601 E. Hazelton Ave., P.O. Box 2009, S!k., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CKa RECEIVED eY DATE PERMR NO. -- INFO CASH EN 13:4 IMEV - C � ( t4 2B