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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {208} 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. 13 EL 114 P—) E—$ NI-VS Job Address �� V 4 �� fn Z City`� Lot size .' PM Owner's Name t=i�1YV� `'� I�ELTO Address �11�m Phone Contractor FA-2 &L_J]r� ll--Address 5Is$1alsfucense No.`-L3b .� Phone 2ea 51.a- TY.0 OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE E TO'NEA EPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOU AGRICULTURE WELL OTHER WELL PITS/SUMPS F 'INTENDED USE_ TYPE OF WELL EM AREA CONSTRUCTION SPECIFICATIONS i '❑ Industrial ,,, ,.❑_Open Bottom .— a❑.Manteca--.-. Dia..of.Well_Excavation. Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type inn Specifications � K r ❑ Public' 9 3 El Other ❑ Delta"""' -.Depth of Grout 5e Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by ` -- • Repair Work Done ❑ Type of Pump H.P- L - j State Work Done Well Destruction ❑ . Well Diameter Sealing Material {to)50'k Depth t Filler Material:{Below'50'I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION STRUCTION ❑ (No septic system permitted if public sewer is; e h ! i available within 200 feet.} Installation will serve: Residence_ commercial t�Other -a k', Number of living units: Number of'bedrooms I s ' O Character of soil to a depth of 3 feet: _ �1--.-- - ^--•i' —' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity. ; No. Compartments PKG. TREATMENT PLT. R-1- Method of Disposal f Distance to nearest: Well Foundation Property Line . i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line fall i SEEPAGE PITS ItY6epth P,, ._--Size Zo / Number d, SUMPS ❑ Distance to nearest: Well Foundation.— Property 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. Home owner or licensed agent's signature certifies the following: "I certrfy 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 followA certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- ti aws of California. The app 1c ust call fo II re red in cti Co late dra o reverse e. Sign Date: d FOR D RTMENT USE ONLY Application Accepted by Date �U � Area '{ Pit or Grout Inspection by Date I v' Final Inspection by Date 3 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca j 823-71041 J -❑:Tracy.,835-6;385 Applicant-.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,.P.O. Box 2009, Stk., CA 95201 FEE AMOUNT OUF AMOUNT REMITTEDC H RECEIVED BY DATE PERMIT NO. INFO �+ l +EH 1324 IAEV.1/e 51 EH 14-26 o l7