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" i..R. APPLICATION FOR PERMIT ~ r SAN JOAO.UIN'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) r; Application is hereby made to the San Joaquin Local Health Distfict 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. - I Job Address pJ /V �1 a��,�/U /� -_ City n Lot Size _PM 04 � �/ fps _ Q/( Owner's Name �(lfdX_D[-" ddress (I � O Z"'� +S�" "J - 1Cl�.hbno I d v I CbritractorAe�ddrss�, o-. . G. -. �► ,,.��.,.-:...,, _ _ .. -. -,,.. honey—= ,License TYPE OF WELL"/PUMP:- '-_"NEW WELL ❑ WELL"REPLACEMENT"❑--`—DESTRUCTION PK PUMP INSTALLATION,❑ _ SYSTEM REPAIR EJOTHER ❑ a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 'DISPOSAL FLD. l 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 CasingSpecifications ❑ Public ED Other !❑ Delta Depth of Gr'"WSeal :I Type of Grout ❑ Irrigation ___Approx. Depth !❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. ' ate Work Done r' Well Destruction Well Diam ter Sealing Material (top 501 Depth + { Fillerh aterial (Below 50.) r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION -(No septic system ! y permitted if public sewer is i available within 200 feet.] " Installation will serve: Residence_ Commercial_ Other . 11V r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: # .4 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity# - No. Compartments Z f r PKG. TREATMENT PLT. ❑ � � y Method of Disposal .4 Distance to nearest: Well FoundationProperty Line LEACHING LINE ❑ No. & Length of lines Total length/size �1r FILTER BED ❑ Distance"to nearest: Well Foundation Property Line ►" i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well foundation Property Line _ 4 DISPOSAL PONDS ❑ i ! I hereby certify that I have prepared this application and that the workwill 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 compen ' tion laws of California-" The appli must call for all required inspections. Complete drawing n reverse side. ...! _ I Signed Title Date: '7 -r G-- �r'��' FOR DEPARTMENT U ONLY Application Accepted by Date A Area j.�--- Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: tk 466-67$1 LJ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 ,tom Applicant:Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA FEE AMOUNT DUE AM INFO UNOT REMITTED RECEIVED BY DATE PERMIT NO. ' + EH 13-24(REV.v R 5) C - EH 1429 '06,_ t.., t