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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-678) 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. 0 D' Job Address e--ga �� }�A�-T C� City Lot Size- o� PM Owner's Name Address Phone i:4FtlnCr� d 1 Address Contractor L__ense 7e�. one — TYPE OF WE 41EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �-,�, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 11 r 11 DISTANCE N_CE TO NEATEST_ SPT�CIIS SEWER LINES DISPOSAL TLD. PROP. LINE" I a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED dsF TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Botto ❑ Manteca Dia. of Well Excavation Dia- of Well Casing k Q Domestic/Private LJ Gravel Pack El Tracy Type of Casing Specificat ss 1'1 Public D. Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation j ..Approx. Dlpth� 1"1 Eastern Surface Seal Installed by ^/ r Repair Work Done El Type of Pump WP.- State Work Done Well Destructiont ❑ Well Diameter ; Sealing Material (top 501 i- Depth- iller Material Welow TYPEI ., FzSEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 1 DESTRUCTION it I (No septic system permitted if public sewer is k t '%Navailable�within 200 feet.) Installation wi .selye:_..-.Residence Commercial Other Number of living units: Number of bedrooms 1 4 Character of soil to a depth of feet:` Water table depth . ` SEPTIC TANK ❑ Ty,,e/Mfg Capacity �dy No.C—,M—P rtF ents ' PKG. TREATMENT PLT. ❑ ,� Mettioa of'LSi,"posal� Distance to nearest: Well�/J"d Founlation_/m PropertyfLine LEACHING LINE No! & Length of lines g Q"m } _V Total len thlsize _ �, �.a FILTER1gED ❑ Distance to ne est:l/V611 u = Foun ation Property Line � t SEEPAI E PITS i I Delpth A^t Size) __.Jq o 1A_ Number ,� 0 I SUMPS Distance to ne est: Well -._� Foun ation72!i� -� rope"ertyyLine••^ ` DISPOSAL PONDS ❑ _ t. W- �...+-• ' I hereb�certify that I have prepared this application and that the work will be done in accordance with SanFJoaquin county ordinances, state Laws, and rules and regulations of the San Joaquin Local Health Di§trict. F Home wrier 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 emplo Fany person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifie$$the following: "I ce that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa tion IaM of�7st rnia." The applica cat)f all requi inspections. Complete drawing on reverse side. t Signed _:Title: f Date: ej +� �. F E RTMENT USE ONLY �— 46 Application Accepted by // Date Area Pit or Grout Inspection by Data +' FinalInspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621" ❑ Manteca 823-7104 ❑ Tracy 835-6386 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE. AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO, INFO CASH EH 14-25 +.EH 13.24(REV.1 x 5) O - /