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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE iON AVE., STOCKTON, CA Telephone (209) 456-6781 PERMIT EXPIRES'TYEAR FROM DATE 'ISSUED' - (Complete in Triplicate) 4 �,.. District 'y.:u Appllcation is hereby made to the Sari Joaquin Local Health Dist fora 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 Ryles and Regulations of the San Joaquin Local Heahh District. Job Address Lf_.1.. L/ �c CSG%+ 1 �f r Ci y� 1 Loi Size ��CG�L'PM ' i Phone .7a-7 -.3L:1- Owners Name � ' �-Q,c�(�Addres`s� ~� � /0 .t_?•C } Contractd ttc r�ewUt' � tt Address ` 7� ! �1 ('!License No, �a� _ Phone 3��`S1C S! I - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT G DESTRUCTION L AMOUNT REMFTTED=, r PUMP INSTALLATION = SYSTEM REPAIR ❑ OTHER C PERMIT' NO. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES a DISPOSAL FLD. PROP. LINE CASH FOUNDATION ✓t - _PPJTS/SU.MPS_ ___. v rOTER LSIREN__WELT INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C Industrial ❑ Open Bottom C Manteca Dia. of Well Excavation 1 Dia. of Well Casing D Domestic/Private ❑ Gravel Pack C Tracy Type of Casing Specifications ❑ Public ❑ Other G Delta Depth of Grout Seal Type of Grout Irrigation --4pproz. Depth G Eastern Surface Seal Installed by i Repair Work Done O Type of Pump H. P. i State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 21-' REPAIR/ADDITION ❑ DESTRUCTION G (No septic system permitted if public sewer is available within 200 feet.! Installation will serve:' Residence Commercial Other 1 } Number of living units: -,/— Number ofbedroo Character of soil to a depth of 3 feet: -e•/�, z lel_,' , Water table depth 1 SEPTIC TANK ❑ Type/Mfg 1 Capacity -©I No. Compartments PKG. TREATMENT PLT. ❑ r nJ } Method of Disposal . Distance :to nearest: Well •SQ Foundation �� n ii Property" Line LEACHING LINE FA -l' No. & Length of lines _ Total length/size/A'0X FILTER BED C Distance to nearest: Well /OC Foundation. Property Line i SEEPAGE PITS Ia-Depth Si?. 3 3_4-_ Number � - - SUMPS C Distance'te nearest: Well � Foundation � Property. Line DISPOSAL -PONDS ❑ — # J I. I hereby certify that I have prepared this application and thatthe work will-be,done in`accordance With San Joaquin county ordinances; state laws, and rules and regulations of the San Joaquin Local Heatth'Distiict:u ✓ ! ' J 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, 1 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 tits foAowing: "I certify! hat in the performance -of the work for which this permit is issued, 1 shall employ persons subject to workman's"compensa- tion laws of California:"__�. _ The ap; licantst ca11 for all equired inspections, Complete drawing on reverse side. ^ ""� �� • -_ '�-^ - Signed KGt7'C` Title. J 'Date: FOR D&PARTMENT USE ONLY Application Accepted by or Grout Inspection by Additional Comments: ❑ Stk 466 -Ml C Lodi 368-3627 Applicant - Return all copies to: ,Environmental EH 14-26 Area d/ a23-7104 ❑ Tracy 835-6385 Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t _ FEE AMOUNT bIYEJ' AMOUNT REMFTTED=, CK`# RECEIVED BY DATE PERMIT' NO. INFO CASH 0