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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT J1 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (20) 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address `-4-6 22 City /,a17J2_,. Lot Size 573 *J-2cVPM Owner's Name 0161 R O TO o Address. Phone ` Contractor� �i� �/�� ""ddress rx/1;ze W1.1_(feW Z?k1icense No. Phone TYPE OF WELL/PUMP: NEW..W�LL ❑ L REPLACEMENT El DESTRUCTION El X007 YAA ,�F PUMP INSTAL.LATION-j� � �'S REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION T 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 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public ❑ Other El Delta Depth_bf,drout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern /Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done keza V6,E Well Destruction ❑ Well Diameter Sealiipg Material (top 501 F,12�r VAL V;.e Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ R ; AIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.)`t' 6 Installation will serve: Residence Commercial Other (Y Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth rn SEPTIC TANK L1Type/Mfg Capacity No. Compartments 1 " PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to_nearest:-- Welt Foundation Property Line G 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: "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, I shall employ persons subject to workman's compensa- tion laws of California." The applican I ora cared inspections. Complete drawing on rever side. f" Signed X i��s' Title: F lt'f FOR DEPARTMENT USE ONLY �� ___.. I SKA Application Accepted by � � Date rea r-• Pit or Grout Inspection by - Date - ,Final lnsp6—c_1 n_6ykOJ :'mate Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 ; " Applicant- Return all cies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA alk , FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24(REV.1/85) �,/¢� � 0 EH 14.28 r i