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TI N FOR PERMIT LICA O OAQ•UIN LOCAL HEALTH DISTRICT r d[d v wy 1601 E'HAZELTON:AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES .7 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. i Job Address �-d �E PO T A f✓,-- city 5-y Xn� Lot Size to�X�O� PM Owner's Name L-9 7— AR/S7-Ek __ Address :IAW-1 - Phone � Contractor f--1-&yD .E. N/_aa b .Address License No.�G 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 3 - ❑ Manteca Dia. of Well Excavation } 1,Dia. of Well Casing w ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casirig Specifications ❑ Public ❑ Other Y ❑ Delta I Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by s Repair Work Done ❑ Type of Pump + _ fl.P. t State Work Done Well Destruction ❑ Well Diameter' Sealing Material (top Depth Filler Material (Below 501) r�✓ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION. (No septic system permitted if public sewer is available within 200 feet.} Installation will serve: Residence_ Commercial_ Other-- - '' i ' f Number of living units: Number of bedrooms 4 Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK LlType/Mfg, F Capacity E S No. Compartments PKG. TREATMENT PLT. ❑ i f Method of Disposal Distance to nearest: Well Foundation Property Line s [ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation i Property Line —E SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t I hereby certify that 1 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."Contractoes 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 required inspectio s. Complete drawing on reverse side. Signed X Title: Date: 1/—IF 7 FOR DEPARTMENT USE ONLY " Application Accepted by Date � � � Area II Pit or Grout Inspection Date Final Inspection I Additional Comments: 4-7 -- i ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ Manteca 7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 /t E FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE J PERMIT'NO. INFO + EH 13-24IREV.iie5) c, Q 41\/ rI7—" EH 14.28 J