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S APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT z 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED r (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. IB62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 41,0 -5- City 9774,U Lot Size 6OX )4 PM Owner's Name R0-/'J C A e K Address Phone Z,a Contractor_ r-Llv V4) Jtd04W D Address�'7 AI. License No. Phone S=397/ 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 -(D Tracy_ Type of Casing Specifications 4 4-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by e Repair Work Done ❑ Type of Pump H.P. State Work Done= Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material {Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION (A REPAIRIADDITION DESTRUCTION l I Wo septic system permitted if public sewer is :-- / available within 200 feet.) 4__ r Installation will serve: Residence "_/ Commercial3 Other Pa g L,C- !� Number of living units% Number of bedrooms Character of soil to a depth of 3 feet: dl—Ax, Water table depth SEPTIC TANK ❑ Type/Mfg EX 1 SrinyG T Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 11 LEACHING LINE Ikr No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ell Foundation Foundation D ' Property Line S SEEPAGE PITS 0,r-Depth"° Q_—f Size 4, Number I SUMPS Cl Distance to nearest: Well WA Foundation �a _ Property Line S r 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?;tfict. l 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, l 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 inspect' ns. Complete drawing on%reverse esside. f Signed XI- Title: Date: �7—90 + RTMENT USE ONLY Application Accepted bDate --17`11) Area 1 Pit or Grout Inspection by Date Final Inspection by Date Seo Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Q Manteca 823-7104 ❑ Tracy 835-6385 j Applicant- Return all copies to: Environmental Health Permit/Seiviees 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE i INE AMOUNT DUE AMOUNT REMITTED CK It CASH RECEIVED BY DATE PERMIT'NO. + EH t4 28 1REV.I/H 57 V �w".�/`.'�� 1�� — "� 9V