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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 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 5950 L^fdO�L3�f �� d• City Lot Size PM t Owner's Name Address Phone ContractolS 1Y1 K- e)t f!rA;L f Address ZOZ_'�; F�� MYaTL _ I SMLicense No. Phone 9 �"/3qs— TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ . PUMP INSTALLATION ❑ t SYSTEM REPAIR;❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK * SEINER LINES. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i 1-1 Public 16) XOther7Vcr` Spelta Depth of Grout Seai Type of Grout i I t Irrigation /pr-%.ZQ*pprox. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ WdDiameter i� " ."._� 5ealirlg Material (top 501 Depth r✓ S _ TYPE OF SEPTIC WORK: NEW INSTALLATION ('I REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms a Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK -❑ Type/Mfg Capacity No. Compartments . - PKG. TREATMENT PLT. ❑ Method of Disposal <' Distance to nearest: Well Foundation Property Line 'T r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number n SUMPS U Distance to nearest: Well Foundation Property Line 5+� DISPOSAL PONOS ❑ 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant m t call for al quire( inspections. Complete drawing on reverse side. Signed X Title: 4Nt5 6l�e3Z /S Date: Z>Z7— FOR DEPARTMENT USE ONLY Application Accepted by �`'T� Date V~ Area v 2' Fr/ 3 Pit or Grout Inspection by Data Final Inspection bypater" O Additional Comments: r ❑ Stk 466-6781 L7 Lodi 389-3621 ❑ 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 95241 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT'NO, +.EH 13-24 IhEV,i i e 5) 1 EH 1I-29 I!