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APPLICATION FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT ` .. 1601 E..HAZELTON AVE.,;STOCKTON, CA Telephone (209) 466-6781., PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r :r Application is he 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 —3 6, 3 w r. CrtY �+ lot Size C PM Owner's Name Address T C L Phone fuur�� v ; �r.�, y >• p� — d� se�- r Contractor_ L , L j i ,�gddresslt lJ�-� C= se No. ��" Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ — T PUMP IINSTALLATION'O�""�"_--'SYSTEM REPAIR ❑ OTHER ❑_ W '~ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑-Industrial —E]-OPen Bottom'""""'"-❑"Manteca----Dia.—of_W&II-ExcavationDia:of Well Casing""�'"""�- ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy t Type of Casing Specifications ❑ Public `--O Ot\r 4 �❑ Delta Depth of Grout Seal Type of Grout Ll Irrigation —Approx. Depth ,f❑ Eastern I Surface Seal Installed by Repair Work Done ❑ Type of.RampI 4 H.P. State.Work_Done Well Destruction ❑ Wel! Dia 1�r Sealing Mate ial (top 50') R 1 Depth � Filler Material t(Below 50') - - TYPE OF SEPTIC WORK: NEW lLLATION 0 REPAIR/AD_DITION.( t:STRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residenceommercial_ ,Other ' ` Number of-living units: ( . Num'aer of bedrooms� RY Character of soil to a depth of 3 feet: 4 � 1 Water table depth SEPTIC TANK ❑ Type/Mfg e k Capacity N No. Compartments i PKG. TREATMENT PLT. Clt _ r Method of Disposal i Distance to nearest: Well Foundation ww PnopertyLni e LEACHING LINE M—N-o-. & Length of lines ; Total length/size Q FILTER 8EDr ❑ Distance to nearest: Welt _ Foundationp' r y' �..-- Pro a Line SEEPAGE PITS Size J Number SUMPS ❑ Distance to nearest: Well Foundation . p operty Line J` DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will-be done in accordance with SwJoaquin county ordinances, state laws, and P ' rules and regulations of the San Joaquin Local Health Districts-'-` ` `t 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 $ e any person in such nner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certi#les following: "I'ce i hat in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws ofrfornia." Thea licant m cal for all req 'red spectio . Co p t dr ng on reverse side www, Signed -x� Trtle: data: _ FOR DEPARTMENT USE ONLY Application Accepted by x Date 2~ Area d i Pio Grout Inspection by6M Date 1�-3 a—` Final Inspection by Date ta`3 a— Additional Comments: t ❑ Stk 466-67$1 ❑Lodi 369-3621 ❑ Manteca :823-7104 ❑ Tracy 835-6385 - 7 Applicant-Return all copies to: Environments!Health Permit/.Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT,REMITTED C RECEIVED BY DATE PERMIT NO. INFO +EH13-24(REV.t/as) __7C,7�°I� EH 14-26