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h; APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT it 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I'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. !l F '0 �7 }�Y M AlEQ Cit sr�+/Y " Lot Size PM Job Address � r/� � `I �+ Y / i IY AN!;,..7 C ,�� Phone f . Owner's Name �� Address �/7" le Lw� Ct�A� fI /1► Address Contractor 6 /V Licen iVa Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSACFLD. 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 D Tracy Type of Casing Specifications F'1 Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout �h ! I Irrigation Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ ,I Well Destruction ❑ Well Diameter Sealing Material [top 501 v i Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDiTIONA DESTRUCTION I I (No septic system permitted if public sewer is it available within 200.feet.) f Installation will serve: Residence%. Commercial_ Other Number of living units: Number of bedrooms !71 i Character of soil to a depth of 3 feet: A dZb09g5kiw� G`104 Water table depth (� ,, SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.:.TREATMENT PLT. ❑ � � Method of Disposal Distance to nearest: Well Foundation Property lineop ' LEACHING LINE No. & Length of lines Total length/size Z / l-L I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1741 Depth Size Number SUMPS ❑ Distance to nearest: Welles Foundation Property Line II DISPOSAL PONDS ❑ 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 "?lj certifies the following; i certif'that in the performance of the work for which this permit is issued, I steal!employ ' y pe p p y persons subject to workman's compensa tion laws of California." The applicant t II r all'�re 're inspe tions.Compl drawing on reverse side. ' Signe I Title: r Date: FOR IDEPARTIVIENT USE ONLY Application Accepted by U-) Date j~Z "// G Area Pit or Got Inspection by Date ZS final Inspection by " _6n Date 'z ./ST/ a F b 0-4/nni � "D /' n Additional Cammerits: [o ` V 1'Ya I/vf 2 r f s� e 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 V ❑ Tracy 835-6385 jz9 e'rjcr e+k _12�rL Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED y CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-241REV.1/H51 ` O f" _ � fr7{� CGG•� EH 14-26 `/ Il/l'lJll`jJ ((�� d1/!i 1