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"3 APPLICATION FOR PERMIT „ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (f I (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 i 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 k Local Health District. ,.[� Job Address 4Y City "'�-t Lot Size C PM Z __K_Owner's Name W - Sn1 t- Address -Phone Contractor's Name License hKt -t, `License No. a ?D Phon TYPE OF WELL/PU,MP: NEW WELL ❑ .WELL REPLACEMENT�IS�POSAL STRUCTION ❑ uINSTALLATiON ❑ ° SYSTEM REPAIROTHER ❑ i DISTANCE TO NEAREST:rtSEPTIC T y f SEWER LINES FLD. PROP. LINE FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA RUCTION SPECIFICATIONS El Industrial I ❑ Open Bottom ❑ Manteca Dia. of We ation Dia. of Well Casing _ ❑ Domestic/Private" `❑ Gravel Pack ❑ Trac Type of Casing Specifications ❑ Public j ❑ Other elta Depth of Grout Seal Type of Grout ,s J ❑ Irrigation --Approx. De ❑ Eastern' Surface Seal Installed by 1 I✓ Repair Work Done ❑ Type of P H�P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 S Depth Filler Material {Below 501 N TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION _,DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence Y--.Commercial s 'Other i I. Number of living units:—IL- Number of b drooms Character of soil to a depth of 3 feet: .. L'_ 4C7/3-" n Water-table depth. j. SEPTIC TANK i C] Type/Mfg Capacity No. Compartments _ PKG. TREATMENT PLT. ❑ f` j' Method of Disposal x Distance to nearest: Well Foundation ) -F Property Line s' LEACHING LINE ,� No. & Length of lines " ''�Total-length/size FILTER BED ❑ Distance to nearest':'— Well- —Founda ion - Pro`pertyryineL � I� SEEPAGE PITS ❑ Depth °Size Number SUMPS X bistance to nearest: We)I Foundation ,_. 'fL Property Line _ DISPOSAL PONDS ❑' r r ff I hereby certify thael have prepared-this application and that tMPork will.be done in accordance with untv er a laws, and rules and regulations of,tlie 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 iss ed, I shall not employ any person n such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub contra ting signature certifies the following."I certify;fhat in the performance of"the work for which this permit is issued, I shall employ persons subject to workma 's compensa- tion lawsof Ca1'rfor`' 4 The applicant m for all zr.e ad inspect ons. Complete drawing on reverse sib — nr / Signed Title: �[� Date: FOR DEPA MENT USE•ONLY i~ f Application Accepted by < Date Area j l 6Pit or Grout Inspection by MIA Date Final Inspection-by Date Additional Comments: 1 ❑ Stk 466-6781 I ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant-Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 --ft .......�.....�-w-, I; INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. t t _� + EH 13-24 1REV.10!831 .tom I/CI/{r{ t t EH 14-28 a `' ( 4 b 21-,9CJ l