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4 6. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL-HEALTH DISTRICT 4 -�..�1601 E. HAZEL 10N 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 District. Job Address dfi�_ City ZWWIV&9�1 Lot Size PM _ /z t Owner's Name C C x Address0 ��Cf�l Phone 'rS SSI ` PhoneAddress License No.�Contractor TYPE b 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 I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L Q Domestic/Private ❑ Gravel Pack ❑ Tracy -- Type of'Casing Specifications .e FI Public lI Other ❑ Delta Depth of Grout Seal Type of.Grout__.. _- I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done _ Well Destruction ❑ Well Diameter Sealing.Material (top 501 � } Depth Filler Material {Below 50') t 1" I TYPE OF SEPTIC WORK: NEW INSTALLATIONX REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) I Installation will serve: Residence Commercial ..Other .-4> r ---- r p Number of living units: _ft Number of bedrooms y � �V)-' '�- _- Character of soil to a depth of 3 feel: A it//�{�Lcm IA-4— Water table depth :SEPTIC TANK ❑ Type/Mfg �; d'LI Capacity No. Compartments PKG.iTREATMENT PLT. ❑ _ j Method of Disposal Fl Property Line "Distance to nearest: Well Foundation LEACHING LINE ❑ No. & Length of lines �- �(L� � Total length/size $ T� FILTER BED _Distance to nearest: Well Alec Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 District. I Home owner or ticensed`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 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 10 workman's compensa- tion laws'df California." I The applicant mustcalftir,a! r'3qu'o inspections. Complete drawing on reverse side. Signed X �-G :—��. �� - --- Title:• � Date: �+�� f�-r---=,.M'i-;.,_ -4-� R PMENT USE ONLY I Application Accepted by Da[e b Area Pit or Grout Inspection by, Date Final Inspection b Dat Additional Comments: ❑ Stk 466-6781 19-Lodi—369-3621 ❑ Manteca 823-7104- ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. H6zelton1Ava.,'`P.O. Box 2009,'Stk., CA 95201 ' FEE AMOUNT DUE 4e AMOUNT REMITTED CK 0 SASH RECEIVED BY DATE— PERMIT-NO. I INFO +.EH13-241REV.r/K51 T EH 14.26 d-I