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} APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA �-- Telephone (209) 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 wall/pump and the Rules and Regulations of the San Joaquin Local Health District:;fit, Job Address 67 City 7 C Lot SizePM Owner's Name A1212644 CZ- 17-VOAJ Address S� Phone -3 0 Contractor�FLO.YD E, A400,0Address faO�i(l. Gf�i.a.rl .¢!/E License No. !:S Y71. Phone Cor'- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR 17F_ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other t ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by j Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth I ` Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑• REPAIR/ADDITION ❑ DESTRUCTION V(No septic system permitted if public sewer is F i , available within 200 feet.) Installation will serve: Rest encs ` Commercial ��N Other_ Number of living units: Number of bedrooms �' l Character of soil to a depth of 3 feet: '� Water table depth SEPTIC TANK ❑ Type/Mfffg; Capacity No. Compartments PKG, TREATMENT PLT. 11 [ '� Method of Disposal Distance to nearest:------Weil—----Foundation Property Line I 1 _ i LEACHING LINE ❑ No. & L'ength of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size . ' Number SUMPS ❑ Distance to nearest:. Well Foundation Property Line ' DISPOSAL PONDS ❑ I r 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 performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." r The applicant must call for all required inspection& Complete drawing on reverse side. I. Signed T, Title: .&.. . r-, Date: 4--24:747 FOR-DEPARTMENT USE ONLY Application Accepted by } A Date -5 2 / —E�2 Area 12n r Pit or Grout Inspection b Date Final Inspection Date o� / `� G k Additional Comments: 415? /,1 ;Z, ❑ Stk 466-6781 ❑ Lodi 369-3621 ElManteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEEi INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 11tEY.i i e sl EH 14-29 !!!