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h. APPLICATION FOR PERMIT .I J: I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ' ' PERMIT EXPIRES TYEAR FROM DATE ISSUED fr J •. I� (Complete in Triplicate) C�/� ,,pQ ✓q� .y . Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein de&ibed. This,�p ication,is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Rwlafions of the San �fi2quin s�� Local Health District. Job Address ! i C City Lot Size �pr Owner's Name Address _�E 1:7-AD 4!f i Phone 36 ?–,511 Contractor aES7 L Eit� 1 F.9C Address t�fm l f� 1 (cense No. Phone 0_4 U13f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION A SYSTEM REPAIR ❑ OTHER ❑ r. "DISTANCE TO-NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLO. 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 Ria. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 171 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout Irrigation —F-Approx. Depth l I Eastern 5t rface Seal Installed by s Repair Work Done i� Type of Pum H,P. State Work Hone P Well Destruction ❑ Welh Diameter L' Sealing Material (top 50') / 9 Depth Filter Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION (:) REPAIWADDITION I i DESTRUCTION l I Wo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms x Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i9 Method of Disposal t 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 i SEEPAGE PITS l I Depth Size Number SUMPS x -C1 pistance tit nearest. Well% - Foundation rProperty L"in0— – 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 t rules and regulations of the San Joaquin Local Health Di§trict. Homo 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 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." it The applicant must call for ail required inspections. Complete drawing on reverse side. SignedX Title: Date: 1 '- FOR DEPARTMENT USE ONLY Application Accepted by Date l Area r Pit or Grout Inspection by Date Final Inspection by --SMV Date ^Z t Additional Comments: ❑ Stk 466-6781 ❑ Lodi. 369-3621 ❑ 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 ii FEE I CK Ok INFO AMOUNT DUE AMOUNT REMITTED CASH(/► RECEIVED BY DATE PERMITNO. +.EH 13-24(REV.1 N 5) `'I L-1 5Ili EH 14-26 7 i I�