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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 'I 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 4;71 � 4y � �` A91City Lot Size PM Owner's Name 1oa41 Address CAtractor ae Address License No�012 Z/ Phone "G8 fZ& TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ .1-PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"7 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I i,Irrigation f - Approx. Depth I I Eastern Surface Seal installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done u Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION ! I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_✓ Commercial— Other Number of living units: —I— Number o edrooms Z--- M Character of soil to a depth of 3 feet: l --_,__ Water table depth vG/ SEPTIC TANK ❑ Type/Mfg rapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CY No. & Length of lines V Total length/size Q FILTER BED © Distance to nearest: Well 1213 Foundation� Property Line I S#EPAGE PITS !" Depth 'Size Number SUMPS ❑ Distance to nearest: Well ISS Foundation ga r Property Line DISPOSAL PONDS ❑ 1 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 7) rules and regulations of the San Joaquin Local.Health Diltrict. Hume owner or licensed agent's signature` rtifies 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 perforniVice of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." Y The applicanibmust call fir 41 required,/nspejftions. Complete drawing on reverse side. i Signed X_ Title: �W��/rDate: 1—,2 7— 07 FOR DEPARTMENT USE ONLY Application Accepted b Date __ 70 Area 1.2 6iltoGrout inspection byDate '��inal Inspection by ate J, �( Additional Comments: 11 Stk 466-6781 LJLodi 369-3621 ❑ Manteca 823-7104t ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201FEE r /1 INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY / DATE PERMIT No. EH 13-24 tflEV. EH 14-26