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f APPLICATION FOR PERMIT R SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. � ( �/�� Job Address I" `--�"° ' 0 Ve' City Lot Size 50 )e 100 PM Owner's NameetIZAj?—I!!� 1\ Address 452-0 W 1rl-e, SA Phone 531 576 - i 5 Contractor Address License No. Phone TYPE OF WELL/PUMFV NEW WELL ❑ , WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION '. _ SYSTEM REPAIRIV_ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK oZS SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G ❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' Specifications r ❑ Public ❑ Other ❑ Delta Depth of Grout Sea] Type of Grout LJ , ❑ Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 C� 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 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ 'Type/Mfg / _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ I " Method of Disposal �� Distance to nearest: Well j Foundation Property Line LEACHING LINE :❑ 1Fo.rh angth of lines Jotal length/size FILTER BED ❑ Di n e to nearest: Well Foundation Property Line �] ` h� SEEPAGE PITS 171Depth, Z X1 _ i e �� ,plumber — S SUMPS 1� Distance to nearest: Well /1/ Foundation 7G Property Line 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 peiformance 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 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 re uired inspections. Complete drawing on reverse side. s Signed �+ 'Title: &X r _ Date: - FORD PARTMENT USE ONLY Application Accepted by Date �� ' Area I Pit or Grout Inspection by Date f Final Inspection by Date l dTonal Comments: r Stk 466-6781 C1 Loci 369-3621 ❑ Ma 823-7104 ElTracy 835-6385 Ap 'cant- 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 H RECEIVED BY DATE PERMIT'NO. 4.EH 13-24(REV.V/s 5) cis, n o 5zs I I—)z—%"Sr 3 841 EH 1426 1