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{ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT a ' 1601 E.%HAZEL i ON`AVE., STOCKTON, CA Telephone (209) 466-6781 r 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 G: dU o L e— 4, - City ._5 77L 4), Lot Size A' PM Owner's Name 11A1I .!�>AW S Address ' .�.4+yt� - Phone � Oto L Contractor � Z> 16;*:• &A2g P Address ),.t Aitl License No.13 a2 b Phone 7 TYPE OF WELL/PUMP: . NEW.,INELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ .-_ .. . r PMP 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 ❑ Domestic/Private ❑'Grave! Pack ❑ Tracy Type of Casing % Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation �pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done El Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 'DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other I'. Number of living units: Number of bedroomsa`t 4 Character of soil to a dept hi of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg I I Capacity j L No. Compartments PKG. TREATMENT PLT. ❑ + P �: Y ''Method of Disposal Distance to nearest:' Well Foundation __- Property Line 1 LEACHING LINE ❑ No. & Length#of lines Total length/site FILTER BED ❑ Distance to nearest: Well-- Foundation---> --- --- --,Property Line SEEPAGE PITS ❑ I.Depth Size Number? e SUMPS 17Distance to nearest: Well ' Foundation Property Line DISPOSAL PONDS ❑ 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 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 suchmanner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following:"I cart!y 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 inspections. Co lete drawing on reverse side. ' 7�--~wIT 7 ' Signed Title: Date: _ ill FOR DEPARTMENT USE ONLY j ' Application Accepted by h Area I Pit or Grout Inspection by . Date Fin spection by � Date t Additional Comments: d ❑ Stk 4664781 ❑ Lod`i 3679-3621 ❑ Ma eco WT-1 104+ ❑ Traci/8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave.,P.O. Box 2009, Stk., CA 95201 FF INFO AMOUNT DG"—E — AMOUNT REMITTEO�x-�ASFi RECEIVEDY B ` DATE PERMIT NO. r + EH 13-24 EH 1429{REV.i/e s> 3- Y-S171 77- 54' i