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�. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 (.Z City 4—"' Lot Size rPM ; _ r Owner's Name K�.�-tt _Tf!JAddress S0 t� leA_� IRS Phone Q Contractor �CLk-R.Address Sr�4 �{��o0i/�� License No. Phone TYPE O E 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 ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ll Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _..Approxi Depth I I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H.P. State Work Do e Weil Destruction ❑ Well Diameter Sealing Material (top 50'1 e 'Q.•: Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION E-I DESTRUCTIO lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units:y Number of bedrooms Character of soil to a depth of 3 feet: klielw Water table depth SEPTIC TANK Type/Mfg °ti Capacity[��a !R!bl No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 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 SEEPAGE PITS i I Depth j Size Number SUMPS ❑ 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. 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 shalt not employ any person in such manner as to became 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 applicaZtusl call for all i�rad inspections. Co late drawing on reverse side. ^�Signed X1 n�� _ _ Title: 4 Date: 5—�9 — 1 FOR DEPARTMENT USE ONLY G n ction b =inat inspection by •Date 'Z-' Additional Comments: ❑ Stk 466-6781 Lodi ane racy - Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 J FEE INFO A-MOUNT DUE i AMOUNT REMITTED CCK 4 RECEIVED BY DATE } PERMIT*NO. t EH!13-24 IgEV.1-/x 51 E1 14-2e a