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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)* / 4q 6 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 4qlL &kLe� Lame- city C 1v Lot Size/ V, �GR M Owner's Name _kIn )h0� Address S�4 M�--Q Phone C-3 Contractor's Name 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 k1A ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other El Delta Depth of Grout Seal ElIrrigationApprox. Depth 13Eastern Surface Seal Installed by Type of Grout Repair Work Done ❑ Type of Pump H.P.— State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial_ Other available within 200 feet.) Number of living units: i Number of bedrooms 7- Character Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity__f.�C�f� No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal QitM� ance Barest: Wel �oundatio_ property Line LEACHING LINE .op(_ No. & Length of lines (f --�,—�—(; Tojallength/size FILTER BED ❑ Distance to nearest: Well Foundation /40 1� Property Line SEEPAGE PITS Depth 19.5, Size 33 3 )umber .9 SUMPS ElDistance to nearest: Well A ' Foundation DISPOSAL PONDS ❑ Property Line 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 ce 'fy that in the performance of the work for which this permit is issued I shall employ tion laws of California." erid p y persons subject to workman's compensa- tion The appli an must all f r 11 required inspections. Complete drawi g on re rse side s Signed Title: Date: / FOR DEP T ENT USE ONLY Applicatio Accepted by 6 2 Date Area Pit or Grout Inspection b � � pe y � o' _t�-,a'"� Date � � /' Final Inspection by - G^C; p�ei'��- Ad tonal Comments: 466-6781 ❑ Lodi 369-3621 ❑ 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 95201 FEE gMOUNT DUE AMOUNT REMITTED C INFO CASH RECEIVED BY DATE PERMIT"N0. + EH 13-24(REV.10/831 41*3 m �a i, _ EH 14-28 6 11/ !�' �C e% 7 ��` ,r 2711