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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAA-E.TON,AVL., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR;FROM DATE ISSUED. �. r ,r {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.Th15 aWication 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 7 9 15- CARP-1-Al City 7 �' Lot Size C` PM -- Owner's Name /C A'Z 1 la/IlJ� f�E��? Address Phone Contractor's Name 4-10422 License No. 4a--r!----7 - Phone b S-3 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 D Industrial ❑ Open Bottom ❑ Manteca s` Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern ,Surface Seallnstalled by— Repair y Repair Work Done ❑ Type of Pump H,P. State Work Done n a Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Belo 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Ftr DESTRUCTION ❑ Mo septic system permitted if public sewer is i fi available within 200 feet.) Installation will serve: Residence Commercial_ Other,.,,,,, a x Number of living units: � Number of bedrooms Character of soil to a depth of 3 feet: � Water table'depth i SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments- ? PKG. TREATMENT PLT. ❑ �y LS ` f Method of Disposal ' Distance to nearest: Well ti Foundation Property Line t LEACHING LINE No. & Length of lines I Total length'/size O IX Z 1K) �: . FILTER BED ❑ Distance to nearest: Well C2 _ Foundation -10 Property Line SEEPAGE PITS eDaoi _;L-S_f.. —Size -� _ s Number SUMPS ❑ Distance to nearest: Well /04" Foundation .�O � Property Line_ -4 " DISPOSAL PONDS ❑ C� 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 Districtf y i j + 0 Home owner or licensed agent's signature certifies the follow ng: '-'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." The applicant must call for all required inspectionstComplete drawing on reverse side. Signed r Title: t — - Date: g—F� -- Ey r OR DEPARTMENT USE ONLY 8 Application Accepted by v Date Area — Pit or Grout Inspection by ate-_ ��` 5 Final Inspection by ate r Additional Comments: ` ❑ Stk 4664781 ❑ Lodi 363621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 r f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 955201 V 7 i CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE. PERMIT'NO., INFO p� 7 + EH 1324 1REV.16!831 ,�` EH 14-28 -