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0 . H � ' 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 2 L4 Ci Lot Size 2-6744. PM Owner's Nameva * Address A ".t>qq Phon b I 4444�V, Ca. 952 3 L ..d' Contractor *4 $OOS AddressA519W_ ��liC _ LicenseNo, T 7 49e%:r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS 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 f-] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top SO') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION WI—REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation *ill serve: Residence Commercial— Other K Number of living units: J— Number of be ooms Character of soil to a depth of 3 feet: --— I A a Ind P—d—W Water table depth 14& SEPTIC TANK 91 Type/Mfg CapacitylLO0_..qA1a No. Compartments PKG. TREATMENT PLT. ❑ It Method of Disposal Distance to nearest: Weldl 0 Foundation Property Line B-40, LEACHING LINE No. & Length of lines Total length/size FILTER BEDDistance to nearest: 5Nell f �F�ation Property Lin4t, _ SEEPAGE PITS l Depth Size Number y SUMPS �❑ Distance zrest: ^' j F undation 2`Z Prop Line-s_75 DISPOSAL PONDS ❑ ��1 t�` I hereby certify that I have prepared this application and that the work will be done in S—ccrdance with San Joaquiz- ty ordinances, state laws, an 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 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 m 6f all for_4 required i r. ctions. Complete drawing on reverse side. �[ Signed ,_� * �� Title: dwoew Date: 7�Zl�A p q FOR DEPARTMENT USE ONLY l Application Accepted by Date ! rea �! Pit or Grout Inspection by rn` . Date Final Inspection by Date ` Additional Comments: 4 J�C.�' WA� { ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK 0 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. 00+ EH 13-24 IREV,i i H S1 EH 14-26