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3� © APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (2091 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 City -5 Lot Size PM Owner's Name '71M �A I/1_5' Address 5Ayvt Phone 9240-1.3-5-3 Contractor Fe- YD,f-• G[ 000)-----Address- Ads License No. `j� -74 Phone z116r-3971 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 C7 Industrial ❑ Open Bottom ❑ Manteca ";'Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy -.Type of Casing. Specifications 1'1 Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout _- I I Irrigation —_Approxi Depth € I Eastern Surface Seal Installed by _ Repair Work Done ❑ rType 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 Ia REPAIR/ADDITION 4 DESTRUCTION ( I .(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ✓ Commercial_ Other Pa,$L4d 7E.Q Number of living units: _/__ -Number of bedrooms ,-«- - Character of soil to a depth of 3 feet: G I-Eil (Water r table depth j SEPTIC TANK ❑ Type/Mfg R6 I NO Capacity L7t©"' No. Compartments PKG. TREATMENT PLT. ❑ `, — _� Method of Disposal i Distance to nearest: Well N A Foundation Property Line LEACHING LINE PI No. & Length of lines o--.Y1-5 r/A/G,,,...,. Total length/size FILTER BED ❑ Distance to nearest: Well WA Foundation Property Line wz. i SEEPAGE PITS l Depth Size-. 4 Y _ Number i SUMPS ❑ Distance to nearest: Well Foundation h2l Property Line s DISPOSAL PONDS .❑ "'� I hereby certify that I haveprepared 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 must call-for all required i q pections.'Completa'drawing on reverse side. Signed X_� Title: _-. Date: 3-2-3 90 OR DEPARTMENT USE ONLY Application Accepted by 3 Area Pit or Grout Inspection by Date R al Inspection by '� �� Date 3 Q� Additional Comments: A�� diei a K� ❑ Stk 466-6781 ❑ Lodi 369-3621 17 Manteca 823-7104 V ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE Y K it 1 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO. +.EH 13-24(REV. /n 5) EH 14-26