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clV I APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091-466-6781 ' 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address ` Ci Lot-Size G0-1Zo PM 3 ' Owner's Name 4 Address Phone / �/� _ i R�"�//B �/ ' Contractor Address: Licerise No: Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ UJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER-0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE rQ 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 L1_Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by - f- Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is ` available within 200 feet.). Installation will serve: Residence I_ Commercial Other Number of living units: 1 Number of bedrooms n Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ 7 �-,/ Method of Disposal Distance to nearest: Well Foundation _.-.f._ _ Property Line k LEACHING LINE ❑ , No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation -_ Property Line I SEEPAGE PITS } ❑ Depth Size y + Num er SUMPS ❑ Distance to nearest: Well Foundation Property Line ,I 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 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."II The applicant must scall fall requiredl i pections. Complete drawing on reverse side. I Signed Title: ��L��" �J -— Date: 1 5 FOR DEPARTMENT USE ONLY �4 I Application A -----.-;_�-.cce�pt_ d by t �� Date ' f d �I Area l r Pit or Grout Inspection by Date Final Inspection by w Date Additional Comments: ❑ Stk 46&6781 ❑ Lodi: 369-3621 ❑ Manteca -71 ❑ Tracy 83"* Applicant- Return all copies to: Environ ental Heralth Permit/Services 1601 E. Hazelton Ave., P.O. B x 2009, Stk., CA 9,5(201 �1 118' f�2SS VY� Lo Ar f H+R 1 Y �LrOi,r... ' T , I FEEL AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. INFO /`\/ CASH /f/jI� '+ + EN t3241REV.i/esl � ©a �i �] Fr�� Ia 1LY I�� 9 EH]426 t - '°