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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a ;....(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 District. Job Address !T ,v y /� a�s...� t cin, .4 Lot, Size e��] ��]] t�f r-� r� ,edr�� PM Owner's Name A4 D4?Pf-� Address 90` 9"c- (f0/e19/,,f _ Phone Contral Addres ' U _ ��y�"Ci/�PhonZGg�e- --License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 4' DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ t OTHER ❑ % DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLp. PROP" LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [I Industrial" ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Y ❑ Domestic/Private ❑ Gravel Pack 1-1TracyT Dia. of Well Casing Type of Casing ' ❑ Public � Specifications,. l Q Other ❑ Delta Depth of Grout SealiM i Ll Irrigation _p Type of Grout, S ` pprox. Depth ❑ Eastern Surface Seal Installed-by _. _ `�_�-_ Repair Work Done � Type of Pump H"P. L -State Work Done,= ' Well Destruction ❑ Well Diameter Sealing Material {top 60'1 "` Depth Filler Material (Below-50;) TYPE OF SEPTIC WORK: NEW INSTALLATION AREPAIR/ADDITION LlDESTRUCTION LJ (No septic system permitted if public p sewer is 11 available within 200 feet.) Installation will serve: Re " ence i Commercial— Other t Number of living units: Number of bedrooms-31 _ Character of soil[o a depth of 3 feet: SEPTIC TANK ° ❑ Type/Mfg ��"Li[� Water table depth a[0 I t Capacity No. Compartments PKG. TREATMENTiPLT. ❑ "t r 3 Method of Dis o al s Pf Distance to nearest: Well Foundation t 1Property Line LEACHING LINE t ❑ No. & Length of lines Total length/sized 70 Q FILTER eft] ❑ Distance to i nearest: �. _ Foundation 0 Property LineWell SEEPAGE PITS b. ❑ Depth - � f /. p Size - Number SUMPS { t' ❑ Distance to nearest: Well - Foundation 'Property DISPOSAL PONDS ❑ .. .-�-� ij.. ,,...„ ;- Line I hereby certify tFiat-f-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:• ,. Home owner or licensed agent's signature certifies the following: employ an "I certify that in the performance of the work for which this permit is issued, I shall not P Y y person.in 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'tha performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California.", The:appt t ca or red i spections. Complete drawing on reverse side. Signed X Title: } i. Date: FOR DEPARTMENT U$ ONLY Application Accepted by Date Area l� � Pit or Grout Inspection by Data Final Inspection by � (j Date F Additional Comments: S ❑ Stk 466-6781 ❑ Lodi 369-3621 -.❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i i FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY PATE PERMIT'NO. i EH 13-24(REV.Fie5� 1 EH 142$ 6 1.3�