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Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ) ��2,�1 City �j Lot Size PM Owner's Name\� 4�s � IJr[.Y FSC Address �g /�� 1� is s Phone Contractor / Address_ , S dCf4. 64/ License No. 3059.2/ Phone .177J2 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 171 Other ❑ 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 J Depth Filler Material I8elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION VI REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence L� Commercial— Other 4 Number of living units: Number of b rooms r 90 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK !+J Type/Mfg Capacit ad Nn. Gompartments 2- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well_f-.o _ - FoundationProperty Line �Q l LEACHING LINE L01�`No. & Length of lines Total length/size FILTER BED © Distance to nearest: Well je 1 Foundation �._� Property Line �0 SEEPAGE PITS !LV Depth p2 Size Number SUMPS Ll Distance to nearest: Well 1 JVD Foundation�..Q-.�..- Property Line 2-O 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 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicamust call for all required inspections. Complete drawing on reverse side. Signed X - __ T Title: �C[�/�'Li Date: i V FOR DEPARTMENT.U_SE ONLYb Application Accepted by ' ' ' Date Area XP fw& _ " i y or Grout Inspection by Date Final Inspection by/ I Date Additional Comments: C'n it- C1 Stk 466-6781------- LI Lodi- 369-3621---❑-Manteca- 823-7104--- --0 Tracy 835- O W�rC�j'j�'W- TIO� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.-Hazelton Ave. .� s tart LA NATION OF REQ + APPRiV �I yFEE ��i�= INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY pA E ERMIT�NO. x�� +.EH 13-21(REV, 5) 00 7J EH 11-2e /