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APPLICAMN FOR PERMIT SCANNED 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is mieby 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. n ,� M Job Address 18704 6US/ymo fW City M111CA Lot Size PM Owner's Name "C)KN /- 1e-1'j Ldress T �1 Phone Contractor. fflx CA�y<� Addre35" 160 16 OWC License No. `(taps---Phone 81S-&sSq TYPE OF WELL/PUMP: NEW WEAL ❑ __ 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 ("1 Public ❑ Other n Delta Depth of Grout Seal Type of Grout_ I I Irrigation i _Approx. Depth I 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 i Q Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIONi - REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial ther Number of living units: Number of�Ydr�.o� Character of soil to a depth of 3 feet: J - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 00 No. Compartments PKG. TREATMENT PLT. ❑ _._ _T _ _ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE NQ.& Length of lines o Total length/size Igo , FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ft ' 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 pTons. ance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California."The applicant u 1 11 for all [�yuired inspComplete drawing on reverse pside�.. Signed X ve — id '�'`• �"'�"-f Title: 0 ' a- Date: 8�8 FO DEPARTMENT USE ONLY X Application Accepted by 1P"J- Date Area �"1 / 67 Z Pit or Grout Inspection by DDaate/ Finall/Inspection by / / q Dates �O Additional Comments:4O��% ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83 5 i'o,rlf� �.ol ie /►19A da ,� Applicant- Re urn a copies o: E onm�Dtal Heal Per i Se a azelton Ave. p 0. p.�/JIf'e �fe ��EeiV�i/%e (is6� � 09 �F ifislerh// a�li.(�rStty 9dEn�l7✓/a�eG� d_t`;G BfRI✓iE O/�Crril.F i✓ Cf� //d -.s-o ds�' .2..ti �•C6.✓! �rl o— .O > ' yc _ FEE INFO AMOUNT DUUE AMOO/U�NT REMITTED UCASH RECEIVED BY �J �DATE PEERMIT NO. EH 1136 IREV.iix5) EH 1436 6-I-QO !D' �� l��