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X,-, A, APPLICATION FOR PERMIT Y SAN JOAQUIN-LOCAL HEALTH DISTRICT '41 e 0 1- 1601 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District`' s' Job Address,�3 i 91 City I Lot Size P11A Owner's Namli-Z A�)3 0 WS4 t Nu kS Fr.)l ddress 3 I�1 �7, Phone 0 4/ d Contractor!y +� f"cam—Addre s:r 76 A .h License Nod 6____�Z�,..____-Phon4Ve 6''F4 IT 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 j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREAS CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca i Dia. of Well Excavation Dia. of Well Casing 4 El Domestic/Private ❑ Gravel Pack '❑.Tracy Type of Casing . Specifications f ❑ Public ❑ Other ❑ Delta Depth of Grout Seal f Type of Grout ❑ Irrigation ---Approx. DepVi ❑ Eastern •' Surface Seal Installed by h Repair Work Done �. Type of Pump^ FI.P _ _ State Work Done Well Destruction C1 Well Diameter Sealing Material (top 50') ' Depth € Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ,,q3 available within 200 feet.) 9 Installation will serve: Residence Commercial_ Other LJ`' Number of living units: Number of bedrooms nv�//��' Character of soil to a depth of 3 feet: Water table depth Doi SEPTIC TANK1-12Type/Mfg # Capacity No. Compartments ^ . 44_,. PKG. TREATMENT'PLT`❑ ' Method of Disposal i Distance to nearest: Well Foundation Property Line l I LEACHING LINE ❑ No. & Length of lines' Total length/size FILTER BED ❑ Distance to. nearest: Well Foundation Property Line SEEPAGE PITS 1. LI Depth Size Number G SUMPS 1 ❑ Distance to nearest: Well Foundation Property Line t/t DISPOSAL PONDS ❑ ... qqq 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'bistrict. 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, 1 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." The applicantt all for all required inspections. Complete drawing on reverse side. t 6 Signed X -'� `^� 9 —Title: �r�-�L Date: �� `� 'k- ]POR kR DEPARTMENT USE ONLY Application Accepted by Date �G Area ;?f3 s Pit or Grout inspection by Date Final Inspection b Date `� { Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Man eco, 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NQ. y i EH 13-24(REV. /a,5) EH 1425