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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED e (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 R41es and Regulations of the San Joaquin Local Health District. " �J' ` aTj►Ce 1-f l SSU PM Job Address City Lot Size Owner's Name U _'<_4 Al JD 12 UA L. Address _S 1e Phone Contractor —1-0 l+t�� Address r�� /�-t-l� Licenses N No. Y7L Phone 54nf-39'7 I 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 ❑ Manteca Dia. of Well Excavation . ' Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ``� ?�1' Specifications ❑ Public ❑ Other f❑-Delta-.— :Dep Lf%of Grout Seal = ""'` `" Type of Grout ❑ Irrigation --Approx. Depth 1❑ Eastern Surface Seal Installed by ) Repair Work Done ❑ Type of Pump H.P. State Work Done f 1 Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth ( Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 31 available within 200 feet.) ' Installation will serve: Residence� Commercial_ Other Number of living units: I-- Number of bedrooms Character of soil to a depth of 3 feet: CL Water table depth SEPTIC TANK C 1 type/Mfg C e "Capacity )2,4 19 No. Compartments 2- PKG. PKG. TREATMENT PLT'O _ l r.. ' 4_ ...N �. - Method of Disposal 'Distance to nearest: Well R Foundation �� Property Line A7 _RL1,0"C_ WA 72x2- LEACHING LINE .%No & Langth of lines r Total length/size FILTER BED ❑ Distance to nearest Well Foundation Zd Property Line SEEPAGE PITS © epth !Q (1-1 Size 7— ' Number 'SUMPS I Distance to nearest: Well�J -A— Foundation___.�/� Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared-this,applic'ation andthatthe work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health,District:- t 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, I shall not employ any person in such manneras to-become:subject to workman's compensation laws of CaVornia."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." i r, y The applicant must call for all required inspections. Complete drawing on reverse side. Signed Xy Titie: Date: I '. FOR DEPARTMENT USE ONLY IDate 5- . �� Area Application Accepted by Pit or Grout Inspection by I Date Final,Inspection'by Date Additional Comments: # .41 I ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ Manieca 823-7104 ❑ Tracy 836-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,:Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH 18-24(REV,, /85) EH 14 `26 �� ..eek-^' �* � �� gh