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d — Al APPLICATION FOR PERMIT E SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone (209) 466-6781 I� 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 L�]�� V l [ `l��1. _ City C L�t N Lot Size PM 114) Address _' Phone : Owner's Name 1 V, 1-5 1E - �6✓a o --n/ �� f cS Q.Soa0JF Contractor \ Address License No. Phone 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-t CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack LJ Tracy_,_ Type of Casing Specifications l`l Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx..Depth 11 Eastern Surface Seal installed by Repair Work Done F❑ Type of Pump m I H.P. State Work Done Well Destruction ' ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 rA TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION/k INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: RM4 - MOO 0 0 R f to to Li§06sal de th SEPTIC TANK ❑ Type/Mfg fl] ra s'� PKG. TREATMENT PLT. ❑ M o Distance to nearest: WellVCrdi �ftZ Linl�� LEACHING LINE ❑ No. & Length of lineswork �O"T tt� I��S ��` ( .f FILTER BED ❑ Distance to nearest: ' Well SEEPAGE PITS 11 Depth Size _ Number SUMPS D 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 pert.ormance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 scall for ail r quired inspections. Complete drawing on reverse side. Signed XVv l `� � kc�� Title: Date: FOR DEPARTMENT USE ONLY / I Application Accepted by DateArea } t Pit or Grout Inspection by // Date Final Inspection by. Date Additional Comments: # �,T__` 7& ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT NO. INFO + EH 1 3"24 4REV.r/H 51