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APPLICATION FOR PERMIT .-SAIV JO_AQUIN LOCAL HEALTH DISTRICT y 0601;E. HAZEL T ON AVE., STOCKTON, CA ----Telephone (209) 466-6781 k 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 Z-2.11 -5c. 51'.4}!;— (Z City 47'_ Lot Size PM Owner's Name ::rte!-ft-..Z _5:"1"V$s r- ew'i ,/ddress w»y < S� 1P7 Phone 1-16 K" Contractor Address .f G r, i 7TyfL 77-F' h,icense N � Phone TYPE OF WELL/PUMP: NEW WELL ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca_„ Dia. of Well Excavation Dia. of Well Casing D Domestic/Private 1:1Gravel Pack ❑ Tracy ' ' '-r Type of Casing` •` �� +. Specifications f`i Public b�'Other+}f1jJ�,., lelta Dopth of`Grouf Seat `" "�'^^ Type of Grout _ I I Irrigation /t 'tri-i4pprox.;Depth�"I i Easteiri Surf2ce Seal Installed by— - rr - Repair Work Done ❑ Type of Pump +' H,P, State Work Done _ i Well Destruction ❑ Well Diameter Sealing Material (top 50') L.1- ' 7j� P1fdf -- Filler Material IBelow 50')'" TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION LI DESTRUCTION ( I (No septic system permitted.if,public sewer is ~ /"""'"'-'"'-"available Within'200'feet.)• f Installation will serve: Residence J Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: , +' Water table depth V' SEPTIC TANK ❑ Type/Mfg Capacity r' t No. Compartments t PKG. TREATMENT PLT. ❑ ' Method of Disposal, •.I-' Distance to nearest: Well Foundation -Property Line .r 1 LEACHING'ONE ❑ No. &.,Length of lines Total lerigth/size l FILTER BED ❑ Distance tb`` nearest: Well Foundation Property Line SEEPAGE PITSF 11 Depth A Size Number l SUMPS i CI Distance to nearest: Well Foundation 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. 3 } 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-compensatiob-laws-of California:",Gontractor-'s.hiring.or sub-contracting signature y 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." k The applicant must call for all required inspections. Complete drawing on reverse side. l� ry .r'�14k Signed X �. '- Title: r �� l.t51�..! Date: -� f « .. . s FOR DEPARTMENT USE ONLY J Application Accepted by Date � � Area V2"5 Pit or Grout Inspection by - Date Final Inspection by •jJ^-^-y`'�"� Date z ZZ- 9D Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE � f INFO AMOUNT DUE AMOUNT REMITTE1 CASH RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.+i n 51 EH 14-29 >