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APPLICATION FOR PERM I RCC SAN JOAQUIN LOCAL HEALTH O � �1601 E. HAZELTON AVE., STOCKTO , D tvow Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tva g L. (Complete in Triplicate) "Zk 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 713 City S TKA) Lot Size PM Owner's Name DOn!Al L9 oV.4 A/O Address SA- 45 Phone 414'7 9bs Contractor F4,OYO E. 0009 Address 7 Al, AOeZG 5"r' AV—f License No. 4L!'y7L Phone yLr 397/ N TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LI SDISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTU WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO UCTION SPECIFICATIONS ❑ Industrial - ❑ Open Bottom ❑ Manteca . f Well Excavation Dia. of Well Casing ) ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type Casing Specifications f"1 Public ❑ Other ❑ Delta Depth o Grout Seal Type of Grout I I Irrigation —Approx. Depth I I E rn Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material 18elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUC N INo eptic system permitted if public sewer is NJ V a table within 200 feet.) 6� Installation will serve: Residence_ Commercial_ Other J Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size —1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line M SEEPAGE PITS I I Depth Size Number (� 1� SUMPS ❑ Distance to nearest: Well Foundation Property Line k. 1 \ 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 Doltrict. 1 _ 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 taws 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�= �r `' "� Title: &WA. Date: 3 —ei� 90 DEPARTMENT USE ONLY Application Accepted by /woCA trot Date — Area Pit or Grout Inspection by Date Final Inspection bV r Date C� Additional Comments: ❑ 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 2009, Stk., CA 95201 FEE INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH 13-24(REV.1/x5) 7(/ C' ,p� J�O O _ EH 1418 J o O ( /(/ r�j/