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s - 04- V -- fV 1 _ �o �- rod APPLICATION FOR PERMIT d6�AN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. rg � Job Address V 1 A) 6-12I� City Lot Size SOX/00 PM Owner's Name DAU/.5 Address> 75. VfNE. Phone Contractor &yFpftu�!S, G r, :Fp6ress /Q= I), MOO Sr—* License No.744Z—_2-Phone - j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ f DESTRUCTION ❑ l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL-D:-- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 4-TS7SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIE S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of W vation -r Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe of Casing Specifications ❑ Public ❑ Other ❑ Depth of Grout Seal Type of Grout - i ❑ Irrigation —Approx. ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Pump H.P. State Work done Well Destructio Well Diameter Sealing Mate`nal ltop 50'1 7 y i Depth Filler Material {Below 50'1 `TYPE om- 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_ Commercial— Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ' E Water table depth SEPTIC TANK ❑ Type/Mfg ` h r Capacity—L-- No. Compartments PKG. TREATMENT PLT:-13 .r \ .r Method of Disposal (� -Distance to nearest Well ' Foundation Property Line LEACHING LINE ❑ No.,& Length of lines Total length/size FILTER BED ❑ Distance to-nearest:- Well Foundation Property Line SEEPAGE PITS j © Depth Size Number SUMPS ❑ Distance Ko Barest: ; Well Foundation s Property Line DISPOSAL PONDS ❑ 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:g g g: "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 i 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 applic r ust call for all req ired inspectiot>rs.,Complete drawing on rever a si e. Signed X Title: _- � I �l , Date• - I FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection bb Date Final Inspection by �< Date _ Additional Comments: "�' "d J /tea J rGiv� r ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ 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 95201 FEE INFO • AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. + EH 1428 1REV.1rN51 J �U� 1 � 1`L`l s-