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.b APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 V PERMIT EXPIRES TYEAR 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 Rules and Regulations of the San Joaquin Local Health District. Job Address l�'? (� �( DS City"LaAI Lot Size PM i � TT Owner's Name 0_4WAe� "A)0 V4:5� Address Phone Contractor A,I-,__�"ua k Address r� 1f9 /1A.1 License N0.2ZC 0- Phone_ S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. ^ 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 t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth I I Eastern Surface Sedl Installed by Repair Work Done ❑ Type of_P-uriip _ H.P. State Work Done_ Well Destruction ❑ Well Diameter 7 -` `:Sealing Material (top 501) Depth Filler Material'(Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION_- KEP'IR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is f ; - available within 200 feet.) Installation will serve: Residence Commercial_ Other90 Number of living units: ..._._.-.. _ N64-6'r of`bedroor"i-s Character of soil to,wcleptWbf,3;feet: /a Water table depth/` SEPTIC,,TANK;. ❑-��-Type/Mfg Capacity_zol_l� No. Compartments PKG. TREATMENT PLT. ❑ ;'^=�1 y r� �r Method of Disposal' rr Distance to nearest: Well _ Foundation/r�- Property Line /Q212 5 LEACHING LINE _No. & Length of`lines �— yD /� Total length/size FILTER BED ❑ Distance-to nearest: Well Foundation Property'Line SEEPAGE PITS Depth �'��]' r_Size_ r� / Number _ - SUMPS ❑ Distance to'nearest: Well Foundation Property Line (fY DISPOSAL PONDS ❑ t V 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 r rules and regulations of the San Joaquin.Local Mealth"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'peifm orance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." t i The applicant must callf all Lr ired inspections. Complete drawing on reverse side. Signed X Title: Date: FORReARTIVI IUSE ONLY Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Dat ./ ; Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O, Box 2009, Stk., CA 95201FEE { ' INFO AMOUNT DUE AMOUNT REMITTED -CK RECEIVED BY DATE PERMIT NO. I X -EH f124IREV.t/H 51 1 11.-� i4. EH 14-26 "'�