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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I (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 I 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. 7. [� Job Address s&so __ a /Y City 973C_ 1 Q(,Tot Size PM Owner's Name L-I H�T''� ?'t i( tl t L{ Address —%.L44:e� Phone C) 6 9.o S •� �-� Contractor fltQ Addres v License No. !W �Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REP ACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION W-" 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 C]-Industrials ❑ Open Bottoms - _L1 Manteca �Qia.;af.:Well Excavation _ _ _ Dia. of.Well Casing C�omestic/Private Ll Gravel Pack ❑ Tracy Type of Casing T Specifications Cl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _Approx. De th i 1 Eastern Surface Seal Installed by _ Repair Work Done El Type of Pump Uh H.P. A State Work Done Well Destruction ❑ Well Diameter ;I Sealing Material (top 5011 Depth—143 Fiber Material (Below 5411 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence—'Commercial— Other Number of living units: Number of bedrooms Tt �/� �`Character of soil to a depth of 3 feet: ei MI ANR SEPTIC TANK ❑ Type/Mfg Capacity �a� Uig PKG. TREATMENT PLT. ❑ MAYh4i 4 rel Distance to nearest: Well Foundation 90 J�"�y,LiJVAA ' I LEACHING LINE ❑ No. & Length of lines Ipol4� FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size _ Number ' SUMPS ❑. Distance to nearest: Well Foundation Property Line . �D.lSP05ALbPONDS w,—=❑ .w� _.� - --- _... -- . _ _ _ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances_state lJanc>1 rules and regulations of the San Joaquin Local Health Di%trict. 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 f 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." 1 The applicant�tllall quit inspections. Complete drawing on reverse side. I Signed X Title: _1ti1P✓ Qfl Date: FOR DEPARTMENT USE ONLY ) Application Accepted by Date �J Area Pit or Grout Inspection by Date Final Inspection by as f _ Date g Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMT'NO. �.EH 1324(REV.c i K 5) EH 14-26 ;,F