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T APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephohe {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) _ Application is hepeby 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.ri � �7 Job Address // dC City tion*;ize PM Owner's Name W f&J6 4-6CI Address _ Phone ._...,,,_.Contractor__-K)_AL Lj� ¥ Addre_ssa ,C)N 1 `a 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 T INTENDED USE TYPEOFWELL - PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Packt ❑ Tracy Type of Casing Specifications 1-1 Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout _ I I irrigation ___Approx..Depth ( I Eastern---Sur-face,Seal-Installed-by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Wel! Destruction ❑ Well Diameter i Sealing Material Itop 50'1 Filler Material (Below 501; ) �) TYPE OF SEPTIC WORKc:.NEW INSTALLATION l It.. REPAiR/ADDITlON41.]:_4*fSTRUCTION I 1 (No septic system permitted if public sewer is (- �„� y -, a 'T """T^" available within 2130 feet./ U) I tnstaliation will server Residence �mercia!_ Other Number of living units: Number ofbedrooms Character of soil to a depth of 3 feet: -Water Water table depth SEPTIC TANK y'pe/Mfg, J_ it�7 Capacity No. Compartments S4_ y PKG. TREATMENT PLT. ❑ A Method ooff�Disposal-. ,70" ,. Distance to nearest: �'1Nelf[s _�"Foundation Property Line- /SLt L LEACHING:I.1NE ' LV--F. & Length of lines o TOf length/size I� - 1. x .A .. ' f � r 1 FILTER BEDf ❑ Distance to �� nearest: Well .,._. Foundation ' PropertyLine SEEPAGE PITS 11 Depth E Size Number SUMPS ❑ Distance toyy'riearest: 1 Well Foundation Property e DISPOSAL PLlONDS ' 4-C4 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 District. Home owner or licensed agent's signaturercertifies the following: "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 becorrie'sulijecfto workman's compensa`tiiin laws df`California. Contractor's hiring or sub-contracting signature ies 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 la f Califor } z The apOic_ t _ call for re irad i s ctio m drawing on rporse side11110 . ,, Q y t Title: w'h �L1 Date: 1 FOR DEPARTMENT USE ONLY G �77y Application Accepted by I . Date ! / 'a fl Area Q E Pit or Grout Inspection by � � Date Final Inspection by p Date Additional Comments: 1 �� d'6 '' Q ❑ Stk 466-6781 ❑ Lodi' 369-3621-,, Cl-Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE ; AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. r +.EH13-24(REV.i/W 5f -7o L J� '�,-S 7 a EH 14' ,�