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r.' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZEL T ON AVE., STOCKTON, CA y Telephone Q09} 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) i 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 2 � 7>E L l??A 2 City S 22d-42 Lot Size PM /r ,� Owner's Name FLEin/iPl6 Address �i4�lE Phone Contractor FLe?YZ> Lr1"-lb Address 7_�/._.>s,��1.B�.��- License No. Phone_ 4 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 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 T-1 Public ❑ Other -❑ Delta- - Deptfi df-Grout Seal T Type of Grout i I Irrigation _Approx. Depth t I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump 1H.P. _ _ State Work'Done Well Destruction ❑ Well Diameter Sealing Material (top'501 Depth T Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION €1 REPAIR/ADDITION 13 DESTRUCTIONAl (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ZCommercial— Other Number of living units: Number of bedrooms y 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 7. FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: Well -Foundation Property Line 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 Di§ttict. 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed x Title: Date: -1'4Z FOR /- FOR EPARTMENT USE ONLY Application Accepted by DateArea Pit or Grout Inspection by Date Final Inspection by '� Date 2-- - � Additional Comments: 51 (fe- `! d 4` S' L-t EIStk 466-6781 IDLodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 C O I^C&-tc 4-r --�4 ,o o vZ t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 0FEE p INFO AMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY DATE PERMIT'NO. +..EH13-21(REV. /K 51 dC�. ,S w c o � � ,17��' 3i? EH 14-28