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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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. O V 1' Job Address 7�� k , DUrIP&M Ferrer_ City Lot Size 4VQ Ae-Mir PM Owner's Name SogerTor ^T Address 39So W, Phone Contractor 5*00V Address 00.f 47 C& . License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 11 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 r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public 71 Other 171 Delta Depth of Grout Seal Type of Grout ---- I I Irrigation —._Approx, Depth I I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 r� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ff—ow;ldt' ly Number of living units: ___ Number of bedrooms Character of soil to a depth of 3 feet: L' r SEPTIC TANK m Type FEiS }�{ Water table depth JJ�' YP 9 Capacity J<dad No. Compartments PKG. TREATMENT PLT. ❑ 1. Method of Disposal Distance to nearest: Well ^•'!S� Foundation Lo • -__ Property Line LEACHING LINE 0 No. & Length of lines Sr" z Total length/size ! as FILTER BED ❑ Distance to nearest: Well too'_ Foundation Property Line � SEEPAGE PITS 11 Depth Size X 1 P --- Number SUMPS JI Distance to nearest: Well D Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that She 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, 1 shall employ persons subject to workman's compensa- tion laws of California." - 5 The applicant m st call for all required inspections. Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY ' Application Accepted by :A&W15&e Afk-1 Date J ° Area �1 Pit or Grout Inspection by Date Final Inspection by �r.+ Date 16 ?/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 EI Manteca 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 (CIf— K RECEIVED BY DATE PERMIT NO. EH 13-24+ EH1f2BIREV.tiwsl !/ / rev /�/ 1 ) 2Gp6 � t1-01sJ