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APPLICATION FOR PERMIT "eAN JOAQUIN LOCAL HEALTH DISTR1tF 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 r"S� A / �l� T-t7� C�fl_ City w�1 Lot Size IS�J— PM i1SL�f�sEG iSEa�-Tv. ' Owner's Na�zm�e —►�O �cok=�D�.ES �rAd�dres�s Pho Contractor T�G�1�.J�-, + 7 Address% ! �L7 z�Z•W�ii. License No � 2ne / 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications \ I'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Irrigation _.Approx. Depth 1 I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ v Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial X Other Number of living units: Number f bedrooms f Character of soil to a depth of 3 feet: / Water table depth SEPTIC TANK V Type/Mcg Capacity61L)Jo. Compartments PKG. TREATMENT PLT. ❑ � Method of Disposal .� � Distance to nearest: Well(� Foundation 1 Property Line LEACHING LINE X No. & Length of lines Z 61' 100' Gb, a Total length/size zoo,L 9C t FILTER BED L1 Distance to nearest: Well Foundation k2D1'i" Property Line SEEPAGE PITS I I Depth Size Number \ r SUMPS ❑ Distance to nearest: Well Foundation Property Line .']w 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 of 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 taws 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call for all requipitliinspeclions. Complete drawing on reverse side. Signed X Title: '�-STf MtO.TI,�'(L Date: E5 -_Z<52-'3)n FOR?NM USE ONLY (� Application Accepted by X�.AM4d�\\y \NORDate Area 9L© I-zG ACU Pit or Grout Inspection by `^A Date 1Final Inspection bv��`�, Date Additional Comments: t �z[� H'7 /�Sf V / 00lf P.QIr¢ &'/.uf LDStk 466-6781 ❑ Lodi 369-3621 171 Manteca 823-7104 ❑ TracY 835-6385 I;np Ok �-4'ra gLtru+/ �+ o Ic 4r r-yam Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. B StikµCA 9520011 �^ FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED aY DATE PERMIT NO. INFO f CASH + EH 1334 IREV.v x e) 11� ll `I t o L7 016 l� o-� D-asoa `gam EH 11-]a