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7 T - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Distfiict. A Job Address b% P111J E'sT k60A City ' Q"&X* +Lp ot Size PM- Co e,. tr S, se A i_� C ` ' ,gyp 5-7-6 3 Owner's Name RA 0 �9k� fz Address _ -7�+`+ Phone �Yt ~ � Contractor _ ,address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 G Manteca Dia. of Well Excavation Dia, of Well Casing G Domestic/Private I- Gravel Pack ❑ Tracy Type of Casing Specifications ("1 Public Cl Other 171 Delta Depth of Grout Seal Type of Grout — I 1 Irrigation Approx. Depth t I Eastern Surface Seal Installed by ---..... -- Repair Work Done ❑ Type of Pump H.P- State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'I - TYPE OF SEPTIC WORK: NEW INSTALLATION , REPAIR/ADDITION 1 ? DESTRUCTION l I (No septic system permitted if public sewer is f/ available within 2170 feet.} installation will serve: Residence_ Commercial____ Other Number of living units: 3 Number of bedrooms 3 .__ Character of soil to a depth of 3 feet: _ti.- .,, jr Water table depth SEPTIC TANK ❑ Type/Mfg Capacity I No. Compartments—� PKG. TREATMENT PLT-❑ n , Method of Disposal Distance to nearest: Well Foundation Z� Property Line '? LEACHING LINE - No. & Length of lines Total length/size Z1110, FILTER BED ❑ Distance to nearest: Wel! f Foundation ��— Property Line 70 .-�.. SEEPAGE PITS I : Depth Size _ Number SUMPS L) 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 Diltrict. Home owner or licensed agent's signature certifies the following: "I certify that in the pertomtance 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."Contractors 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 comps sa- tion laws of California." The applican st c911 II requ ! inspections. Complete drawing on reverse side. Signed X -n-041A- for — Title: 0 OJ t4 IE rte. Date: s-r r S-c !J FOR DEPARTMENT USE ONLY Application Accepted by Date d Area Pit or Grout Inspection by Data Final Inspection by Dal Additional Comments: ❑ Slit 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 L] Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY D/A�TE�} PERMIT NO. * EH 13-24(REV,ii x5: /� �� r V�/ ' (.f I_ V.S �-1A� EH 14@B v I 'SFJ v �T