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ZI v APPLICATION FOR PERMIT »* A SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEI-TON 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 fqr 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 T�o /� `/`l��/I PJ (K.�l City �C Lot Size ��A PM Q/ c Owner's Name �eL AJ Address ly '�/NG Phone J X 33 Contractor's Name �G .A0011 License No. 304 7I Phone 36,,t .3,73, TYPE OF WELL/ UMP: NEW WELL ❑ WELL MEPLACEMENT ❑ 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 Die. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---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 ❑ R PAIR/AD ITIOII' ESTRUCTION ❑ (No septic system permitted if.public sewer is available within 200 feet.) Installation will serve: ResidenceCommercial_ Other Number of living units:__�_ Number=fmsCharacter of soil to a depth of 3 feet: �,A 19/�'� Water table depth SE�T'IC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ,EolNo. &Length of lines - - Total length/size FILTER BED ❑ Distance to nearest: Well�OO+ Foundation Property Line .SEEPAGE PITS Depth Size rr Number — SUMPS ❑ Distance to nearest: Welt 01 Foundation lo$t Property Line 1 4100 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:"1 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'e cor%*nsatlon laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the perfornlsnce of the work for,rhich this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Califomig:" The applicant must ca f rrequired inspeatlons. Complete drawing on re"side. / Signed X Title: toWAM f' A FOR DSPAR NT USE ONLY Application Acpeptad by: Date � Area (,J Pk or Grout Iniii action by Date / Final Inspection by Data Additional Comments: "' Cir 0 W I ❑ Stk 466-8781 XLodl 368-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant- Return all cop to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED G 3H RECEIVED BY DATE P(�EyRMIT140, a EH 13.24(REV.10/83) C'` EH W26 r