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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES:? 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 U� /92AWMA City2wfl Lot Size PM Owner's Name Address �+ Phone J ContractorCLArfZ-V—&SEPTIC=.Address A-98wA110WIN W6 License No.4� 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications pecifications Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigatioti Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system,permitted if public sewer is .available within 200 feet. Installation will serve: Residence) Commercial_ Other Number of living units:L Number of bedrooms Character of soil to a depth of 3 feet: ? C>.art[ Su Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.-TREATMENT PLT. ❑ + Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 9- No. &Length of lines "~ V Total length/size U FILTER BED A Distance to nearest: Well;Fb jndation - --Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS &*' Distance to nearest: Well Foundation 14� 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 District. Home owner or licensed agents 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 th o ing:"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 f`Cali ria. The applit must all f fired inspections. Complete drawing on reverse side. Q Signed Title:=vl� �lyf 1�- Date: �0 U(r.7 _ FOR DEPARTMENT USE ONLY Application Accepted by Date Area j Pit or Grout Inspection by* Date Final Inspection by Date Additional Commenter 0'h g- X444:tilbTo- D r -.-Or^ao ❑Stk 466-6761 ❑ Lodi 369 1 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT"NO. INFO CASH + EH 13-24 EH 14-18(REV.1/0 5') __76. ,� ,5fa t7.?