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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 Z y S.�G.4 7^ra /cr'" a!; City ks"r,*Jc Al Lot Size - PM- Owner's M"Owner's'Name'z1i 1,4M) Sonis' Address 152 97 1 ivy Phone- 7,4,6 ,� 7� f C/est.4 ContractorD"r/M Sac lf�ioc d 6rkws�.Address f� , ©i 13a 317 W* Pr�rC License No.497-01 M Phone YY457 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ -DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r t .r! t DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� �- " INTENDED USE TYPE OF WELL'"- PROBLEM AREA`;�,CON STRUCTION"SPECIFICATIONS ❑ Industria! ❑ Open.B_ottom El Manteca - ,,D&_of Well Excavation Dia�of.Well Casing h' J"Domestic/Private L1 Gravel-Pack ❑ Tracy Type of Casing I Specifications ❑ Public #, ❑ Other• ❑ Delta s Dept_h.of_GroutKSeal Type of.Grout ❑ Irrigation ---Approx. Depth ❑ Eastern, -Surface Sea! Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Weil'Diameter _ _ Sealing Material (top 50'I f i da s `'= reit Depth - / 'FillerMateriai7(Below 50'I TYPE OF SEPTIC WORK: NEW'INSTALLATION'❑ REPAIR/ADDITION ❑. DESTRUCTION C1 (No septic system permitted if public sewer is p '' available within 200 feet.) C Installation will serve: Residence_ CommercialOther '* ,A Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ... �'� " �1 Water table depth SEPTIC TANK Type/Mfg "'finn CapaciNo. Compartments PKG. TREATMENT PLT. ❑ y Method of Disposal .r Distance to nearest:, Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size E FILTER BED �I�" ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS 1 ❑ Depth Size Number ' SUMPS K\ C]❑ Distance to nearest: Well Foundation i;-r ' perry 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. .. r ,` 4 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 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 inspections, Complete drawing on reverse side. # ! Signed X & w-1n-._..._._._— Title: i Date: g FOR DEPARTMENT USE ONLY.. 1 _ f /� O� Application Accepted by � - Date �"� ..�p q4 I Area / h ry 4 U" 2 ' Pit or Grout Inspection by r" Date ,� �n Final Inspection by � Date Additional Comments: 'Cl' -lY h S 1 �l-Y.C4 C� P� Q S Va ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2000, Stk., CA 95201 FEEa INFO AMOUNT DUE, AMOUNT REMITTED CATH RECEIVED BY DATE PERMIT'NO. a + EH 13-24 EH 1428 IR1;:Y.1/H 51 ` `J . a..? S �\ b� $ 1x-1A?,q ; w