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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT fit 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 1209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Apolicatiof)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 Ihade in compliance with Safi Joaquin tounty 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 �! �i1S�Tr Lt ___ _ City ffte,4100 Lot Size PM r , � R qr Owner's Name 12WAW Address 7- Phone / r K*1 A t LF ]�� 1 r l ' PA.,.La r l U,t r Contractor 40SXW AlUat J*,14rddress 46.1sh7iCI �arQ�`a. ✓A?C� License No. Phone •� 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 Ll Domestic/Private L1 Gravel Pack ❑ Tracy Type of Casing Specifications f'I Public (1 Other f-I Delta Depth of Grout Seal Type of Grout I I Irrigation —_Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material itop 50.1 I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_,0_10*Commercial_ Other Number of living units: Number of bedrooms_36-o 6 Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distanc9 to nearc%t: Well Foundation Property Line R LEACHING LINE No. & Length of lines d Total length/size if FILTER BED ❑ Distance to nearest: Well Foundation____/d Property Line SEEPAGE PITS 40), Depth Size - Number SUMPS L] 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 Diltrict" 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 performancI5 of the work for which this permit is issued, 1 shall employ persons subject to workman's cdrnpe tion laws of California." .L The applicant must call for all required Inspections. Complete drawing on reverse side. Signed K Title: Cly Date: .2�17• 9y F0J1 DEPARTMENT USE ONLY, Application Accepted by z, Date Z-` G Area C:� I Pit or Grout Inspection by Date Final Inspection by Date 8 t� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 x Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 ; FEE INFO A UNT DUE AMOUNT REMITTED RECEIVED BY DATE I'Enmrr'NO. J Elf 1126 C)