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AVidug evitd_ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ;,t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED e o' (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. .f';,:� >�. JobAddress 7 a�� i City Lot Size PIM +/ , Owner's Name �A/ "f767 7 Ph Address � � one Contractor IIA Address / License Na. Phone J /d TYPE OF WELL/PUMP-., ANEW ELL ❑ 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 I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing .❑ Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --__Appro i Depth V, Eastern Surface Seal Installed by `f Repair Work Done ❑ Type of Pump - H.P. State Work Done Well Destruction ❑ Well Diameter #+ Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: .NEW INSTALLATION V fiEPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t`. . ''`` '� available within 200 feet.] k.; Installation will serve: Residence i°= Commercial_. Other t-...... Number of living units: Number of bedrooms ' Character of soil to a depth of 3 feet. S/97vD Water table depth �= SEPTIC TANK ,- Type/Mfg Capacity No. Compartments Y PKG..,TREATME_NT PLT.--E 1 'w. Method lof Disposal s a b Distance to nearest: Well o Foundation Property Line * • LEACHING LINEf## X No. & Length of-,lines Total length/size ...r�.. y FILTER BED ❑ Distance to nearu■est: Well A61') Foundation _ Property Line SEEPAGE PITS F C2 Depth j Size Number II SUMPS � A' ❑ Distance to neares"t" 1/Vel Foundation Property Lin-. DISPOSAL PONDS El - � � � �/w r 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 A rules and regulations of the San Joaquin Local Health District. j I ; A\ I S f Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for-whlch this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors-hiring or sub-contracting signature certifies the following:"I certify that in the perfor nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- ! tion laws of Califor r0 , The applican requ r ons. Complete drawing on reverse side. p � Signed [�'' ]Title: �" Dater f EPARTMENT USE ONLY Application Accepted by Date 1-21 U r Area i p7Pit or Grout Inspection by Date Final Inspection 6y Date� �^p ' r Additional Comments: Yi : ❑ Stk 466-6781 ❑ Lodi;,369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63$5 Applicant- Return all copies td: Environmental'Health'Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 1 z FEE INFO AMOUNT DUE AMOUNT REMITTED K# RECEIVED,BY DATE PERMIT'NO. + EH 13241REV. /e5} 776 EH 1428