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APPLICATION FOR PERMIT r (� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA '1 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address I „ZA4© S CAU-STI N RD City 1 '��'� Lot Size S® Acf�eSPM Owner's Name QAQI O —S 'LVeTrl Address Phone Contractor -1 of CAROLC Address I-So ':�V TrGAJ Ay( License No. 91(/39/1�I` Phone �23 TYPE OF 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f1 Public ❑ Other ❑ Delta Depth of Grout Seal _ Type of Grout . ( ` I I Irrigation _..Approx. Depth t I 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 (Belo 50') C TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION W DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: I Number of Brooms 2 Character of soil to a depth of 3 feet: �y — ^— Water table depth SEPTIC TANK M Type/Mfg weCapac� No. Compartments PKG. TREATMENT PLT. ❑ X200 Method of Disposal Y/Distance to nearest: Well Foundation Property Line LEACHING LINE V!' No. & Length of lines Tptal length/size t FILTER BED ❑ Distance to nearest: Well NO Foundationy Property Line 4/0 SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation 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 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 applicant mu ll for�equiredtpections. Complete drawing on reverse side. AA Signed X � Title: 0"`�'� Date: F � b O FOR DEPARTMENT USE ONLY Application Accepted by Date Area V1 Pit or Grout Inspection by Date Final Inspection by Date—3 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 ❑ Manteca 823-71N ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 fFEENFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY / DATE PERMIT'NO. + EH 13-24(REV.tills) � 1/ I �� / �,�� A� v �l�U �!/ �C.�CJ EH 14-2a !l/