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_ -• s� APPLICATION FOR PERMIT 930 i 2LG� SAN JOAQUIN LOCAL HEALTH DISTRICT i Lf 3�t 1601 E. HAZEL T ON AVE., STOCKTON, CA pa LIN�F64p5 Telephone f209) 466-6781 y PERMIT EXPIRES i YEAR FROM DATE ISSUED q7 (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 ZS C"'O'g-00 ftyo _ city Lot Size PM ' Owner's Namd1 i 1.+7 F�IEI]a c..0 t t ddress ��} -cut.S �j*„� Phone4 ) Lk2t 3P Contractor ale.nti� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR\❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE fir c FOUNDATION AGRICULTURE WELL. OTHER WELL 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 ❑ Public ❑.Other ❑ Delta Depth of Grout Seal Type of Grout (A) ❑ Irrigation —CLApprox. Depth .❑ Eastern Surface Seal Installed by n ; Repair Work Done ❑ Type of Pump H.P. State Work Donep� Well Destruction ❑ Well Diameter Sealing Material (top 501 �( S ,Depth Filler Material (Below 501 U1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 11 DESTRUCTION ❑ (No septic system permitted if public sewer is rl 1 _ L�.< r, _� available within 200 feet.) Installation will serve: Residence Commercial__ Other Number of living units:.�„.._-I Number of bedrooms v Character of soil to a depth of 3 feet: F I Water table depth SEPTIC TANKti ❑ Type/Mfg f 'Capacity L+C)y No. Compartments PKG. TREATMENT PLT. ❑ s Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ 'No. & Length of lines_ 1 `'Total length/size FILTER BED ❑ Distance to nearest: Well Foundation - Property Line �+ SEEPAGE PITS ❑ Depth Size t Nurtlber SUMPS ❑ Distance to nearest.it Well``'ry Foundation _. Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and tha't-the work will tie done"in accordance with Sari Joaquin county ordinances, state laws, and rules and regulations,of the San Joaquin Local Health District. 4k� Home owner or licensed a ent's signature certifies the following:g: "I certify that in tF'se,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;eompe6sation laws of'Califomia."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the worVfor 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 - —Title: �3•y3-@s�adL._” pate: �—Ad DFOR 13EPARTMENT USE ONLY - Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: f S i EO K21KA2 &h N! F60AID Z1lic, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 5512 P b Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Gtr FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT''NO. .f +EH13-241REv.t/a51 'EH 1 '� �n �. - �� -.'• 428 k