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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 EDAVE., STOCKTON, CAT ! Telephone (209) 466-67.81 i 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 I Local Health District. 1 Job Address _//6 6 9_,e: ,,�1��J �• --- City S4 C.A4 of Size t C PM Owner's Name Address Phone Contractor �TK Address Poo B-0 k /9 Z 7 License No.-(Z 7.9 6 Z TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT - DESTRUCTION r PUMP INSTALLATION rn SYSTEM REPAIR ❑ �OTTH�ER _❑ DISTANCE TO NEAREST: SEPTIC TANK IOO �f SEWER LINES J DISPOSAL FI -.[_C1�ROP.1LINE FOUNDATION _34 r!� AGRICULTURE WELL 1t t OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF.WELL PROBLEM AREA CON STRUCTIONr SPECIFICAT! S ; f� In trial ❑ Open Bottom E] Manteca I,- Dia. of Well Excavati . own Dia. of VyeIl;Casing Zomestic/Private D•Glavel Pack O•Tracy Type of Casing- f:a�[.T`_ Spec ificalloris /640 f'i PublicC7 O�er ' Cl Delta Depth of Gout-Seal Type of G uta I I Irrigation � � ' t�s� y g- ��..Approx,i Depth ii�+Eastern Surface Seal Installed by Repair Work Done fjp_Type of Rwmp`.41ZZL to H.P. State Work Don _ (� �' �.� j� Well Destruction la�Well Diameter Seating Mat e'al (top 50'194 Depth 1 Fiber Material T•Below 501 f1� TYPE OF SEPTIC WORK: NEW INSTALLATION ail REPAIR/ADDITION 1 l�DESTRUCTION I 1 INo septic stem permitted if 1 1 6 �v> ��.y#-r A p V- p public sewer is 11% available within 200 feet.): q Installation will serve: Residence Commercial ",.Other Number of living units: I Number of bedrooms ! 1 Character of soil to a depth of 3 feet: f I ., i-' nr Water table depth t XWeIlFoLundation SEPTIC TANK ❑ ftype/MfgCapacity_;_/, No. Compartments PKG. TREATMENT PLT. ❑ v'' � Method of DisposalDistance to nearest Property Line .,�LEACHING LINE ❑ No. & Length of lines Total length/size FIL-TER BED ❑ Distance to nearestt on Property•Line SEEPAGE PITS ( I { Depth i Size Number SUMPS ❑ Distance to nearest=: - lfetl -^ DISPOSAL PONDS r-] -�-'foundation Property,L'ine r i I hereby certify that I have prepared this application and that the work wily be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin'Local Health Di1trict. Home owner or licensed agent's signature certifies the following: "I certifylthat in the performance of the work for which this permit is issued, I shall not employ any parso . such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature f certifies the f owing: I certify that in the performance of the work for which this permit is issued, I shlall employ persons subject to workman's compensa- tion laws o Calif nia." i f The applic nt m t or all r u' I i Co g on a side Signed X Title: Date: RTMENT USE ONLY ~ Application Accepted by ~' y. � spate $ Area Pit or Grol,t Inspection b _ Date-07Final Inspection by Date �+ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369 ❑ Manteca H23 7104 O Tracy 835-638 — : Applicant—-Return "-all copies-to:•Environrrientel Health.Permit/Services`1601-E:HazeltonAve.,-P.O.`Bax,2009;5tk:, CA 95241. EEE IOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT'NO. .-EH13-21(REV.1/n51 r Y v�� go 001�b EH 11-26 V Ub V '1