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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applica-ion 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 Copnty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.-j�{ p� I MZZ Job Address 1'i +`-'t J T1� rQt� _ City wQ Lot Size Y,4(0'+7r,4 Owner's Name 100.�1�E`= Address Phone Contractor t�+{UC.t +- J �7 Address' �+'�f i%JC�t.! _License No.Z!��54 Phone _ TYPE OF WELL/PUMP: NEW WELL i� WELL REPLACEMENT ❑ DESTRUCTION Fl PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER O DISTANCE TO NEAREST: SEPTIC TANK _..__ SEWER LINES DISPOSAL FL.D. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation _...__ Dia, of Well Casing iD Domestic/Private Fl Gravel Pack ❑ Tracy Type of Casing Specifications \ ,rl Public 1.1 Other 1 [I Delta Depth of Grout Seal . _ Type of Grout __ r ' I Irrigation _.Approx. Depth I I Eastern Su+face Seat Installed by Repair Work Done f� Type of Purnp H.P. SIate Work Done Well Destruction FJ Well Diameter .._.-...._�_ Sealing Material (top 50'1 Depth Filler Material (Below 50') —_ -TYPE OF SEPTIC WORK: NEW INSTALLATION I ' REPAIR/ADDITION DESTRUCTION I INo septic system permitted if public sewer is ! available within 200 feet.) Installation will serve: Residence Commercial X Other Number of living units: _-__ Number f bedrooms Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK Type/Mfg Capacity_1,1 �j�L.,No. Compartments PKG. TREATMENT PLT. O ��1 ` I , Method of Disposal Distance to nearest: Well i�OL7 Foundation ito Property t pe V Line �-. LEACHING LINE No. & Length of linesr� � C-61total length/size XFILTER BED El Distance to nearest: Well r��„..0 + Foundation s } Property Line 2�I SEEPAGE PITS I I Depth I Size Number SUMPS L_, Distance to nearest: Well Foundation Property Line DISPOSAL PONDS U ) \ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinance`s, state laws, and rules and regulations of the San Joaquin Local Health Di3trict. Home owner or licensed agent's signature certifies the folowing: "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 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." s The applicant ust call for all requir inspections. Complete drawing on reverse side. r� Signed X _.-_-_-_ Title: .�.STi t�1 a'C!J ' Date: FOR DEPARTMENT USE ONLY a Applicarion Accepted by Date `� !�. Area JU Pit or Grout Inspection by Date Final Inspection by Date . Additional Comments: ZIAolk z% ❑ Stk 466-6781 O Lodi 369-3621 O Manteca 823-7104 O Tracy 835-6385 ;K (,',w A bd,� 0, ,- I _.k f /,j-c 6 K,4. Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. 8,9xA1009, Stk., CA 95201 X577. ;>1f c1- lE•-c�, o..�t+.., -�.-d.., b�,•Yi�/f1*V«J✓e— Ly FEE AMOUNT DUE t AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. tG SU INFO C/ASHH a.EH 1324 IREV.1/$45i �1�1 ll T C D(� owCASH +a-3o-� -DL EH 14 2e 1