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APPLICATION FOR PERMIT '� LfU SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE, STOCKTON, CA Telephone (209) 466-6781 `� --3 / 7 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED V J b (Complete in Triplicate) 4 Application is heteby made to the San Joaquin Local Health District for a permit to construct andlor 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. r Job Address City 7— C_C Lot Size ! AL `fid PM t ) Owner's Name Ir�� 0 Vim_/ G,H,-,,y�Address -9.1 7 .� ij C�W�Q � /&kPhone n t Contractor Address 5,ra Nrt Ag', License No. Phone TYPE OF ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAR �FDATION TANK SEWER LINES DISPOSAL FLD. E AGRICULTUR HER WELL PITS/SUMPS _ INTENDED USE TYPE OF L AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ottom Manteca Dia. of Well Excavation Dia. of Well Casing i 0 Domestic/ e ❑ Gravel Pack ❑ Type of Casing Specifications f I'I Pub c 11 Other In Delta Depth of Grout Seal Type of Grout I I Irrigation __ Approx. Depth I I Eastern a Seal Installed by Repair Work Done ❑ Type of Pum H.P. to Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 �. Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) ! Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 1 Z U t% No. Compartments PKG. TREATMENT PLT. ❑ e Method of Di"posaf i _, Distance to nearest: Well I UU Foundation Eu Property Line LEACHING LINE Ll No. & Length of lines (J Total length/size FILTER SED i-- Distance to nearest. Well/ 0a �— Foundation [L Property Line f SEEPAGE PITS 1 I Depth Size Number SUMPS i.) Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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- tipn laws of California." E The applicant must cap for all required inspections. Complete drawing on reverse side. Jr Signed X itle: U�/�`-eVCl I Date: _ -� i5 FOR DEPARTMENT USE ONLY ,��^^^`L� Application Accepted by i Date✓- r �/l-, Area 13 Pit or Grout Inspecti Data Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Parmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F FEE AMOUNT DUE AMOUNT REMITTED CK INFO H RECEIVED 8Y DATE PERMIT NO. �p� 4.: -EHH f3-24{ ��y--� HEV�'iin5] ! ��.VV �O•w � 'Y;1_ J / . J I ;��7� FH 14-26