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A�A I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephohe (209) 466-6781 PERMIT EXPIRES 1YEAR 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 T �1 � tl� /�C� City Lot Size PM Owner's Name f (r(.ZjT Address Phone o2,2—311 Contractor�h 1r Address —license License No,[%97-7-/ Phone- �i x.77 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 0 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 C] Delta Depth of Grout Seal Type of Grout { I Irrigation _Approx. Depth i I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Seating Material (top 501 Depth Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11rREPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ✓ Commercial_ Other Number of living units: A,-.__ Number o bedrooms �— Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK © Type/Mfg C60i[_- G*C Capacity 14,cu No. Compartments PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well L0 Foundation �� 1 Property Line /`�Q LEACHING LINE CT_ No. & Length of lines O Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS H-_Depth Size Number SUMPS Ll Distance to nearest: Well ° Foundation Property Line 46_g'� f DISPOSAL PONOS ❑ 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 Di§trict. 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 r quired inspections. Complete drawing on reverse side. Signed X �� Title: Cleo K?[.e Date: l r ty FOR DEPARTMENT USE ONLY f Application Accepted by Date �� Area T Z Pit r Grout Inspection by ate Final Inspection b�� f// / A/ Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Cl Tracy 835-6385 Applicant - Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2003, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY DATE ��jiy� PERMIT'NO. a.EH 13-241REV.1/K51 7 O O d 7 O "�' ..�+ �C� _Zn EH 14-2e ! `-r J ✓V