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k s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone 1209! 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED iComplete 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. 1$62 for well/pump and the Ru nd Regulations of the San Joaquin Local Health District. I ^ 972 r 7�it/ 46ellr PM Job Address 9S P47 ��eso,c/ /2-D City s Lot see Owner's Name "DAA) B" - SSOGAddress N. lel,6'ST [.A�� P6one3-3633 Contractor—F-Lel D GcJB4lb L Address C6,r.y, �1_I LL-iAAJ License No. �Y L Phone-1114'-397 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 r 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. .0 State Work Done Well Destruction 1:1Well Diameter Sealing Material (top 501) Depth Filler Material TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if.publicsewer is I available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of Irving units: Number of bedrooms s;..� _ Character of sail to a depth�f 3 feet1 �_ LATy .Water table depth SEPTIC TANK [E'71T /Mfg n �¢�- CapaciNo. Compartments PKG. TREATMENT PLT.❑ Method of Disposal r Distance to nearest: Well -'>V r Foundation 50 Property Line J 1 `LEACHING LINE No. & Length of lines Je_ _ Total length/size FILTER BED ❑ Distance;to nearest: Well. .�O Foundation /adQ Property Line - I - SEEPAGE PITS ffl/Depth I I - / Size 3 ,r Number SUMPS .'0 Distance'to nearest: Well JAO Foundation/i V Property Line l L DISPOSAL PONDS ❑ I I hereby certify that 1 have prepared this application and that the work will be dons t6 irk 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 i 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." I - The applicant must call for all uired.inspectior . omplete drawing on rse side.. Signed Title: — Date: Z *. FOR DEPARTMENT USE ONLY 1V Application Accepted by Date A �J Pit or Grout Inspection by Date rnal Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3611 1.1 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 95101 INFO EEE AMOUNT DUE AMOUNT REMITTED CASH RECErVED BY DATE PERMIT NO. + EN 13.24iREV.If051 .® ., y0 !/ -too EH 1428