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�. APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 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. ry n \ Job Address ��0 {!— � ^y r City `"�N Lot Size pM Owner's Nema, ��S C Address � G✓t �C/ � Phone Contractor Address License No. 3iga 9 Phone L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PRS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rial ❑ Indust ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by 11 Repair Work Done ❑ Type of Pump H.P. State Work Done lY Well Destruction ❑ Wall Dierlleteo- Sealing Material (top 50') Depth ( -I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION El (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence`✓Commercial_ Other N . Number of living units: Number of bedro/^olms _ Character of soil to a depth f 3 feet: �5Lr Water table depth SEPTIC TANK depth A& 9?WT 92ill Capacity No. Compartments PKG. TREATMENT PLT. El � f 0 Method of Disposal Distance to nearest: Well J'.� Foundation !O Property Line ,y/6 LEACHING LINE W$�No. & Length of lines Total length/si - D FILTER BED ❑ Distance to nearest: Well So ` Foundation %D Property Lim LD SEEPAGE PITS AA� Depth C /11!r Size 5/2 Number SUMPS ❑ Distance to nearest: Well!d0" Foundation LD Property Line f f1 DISPOSAL PONDS ❑ 1 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 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, 1 shall employ persons subject to workman's compensa- tion laws of Califor 'a." The applicant at all f all to ad inspections. Complete drawing on reeverm side. Signed Title: daL". Date: . ,00-4c FOR DEPAR ENT USE ONLY �/ Application Accepted by Dasa Ei—If& Am 0 L Ph or Grout Inspection by Date /�7-8'9 Final Inspection � Data Additional Comments: ❑ Stk 4(16-6781 ❑ Lodi 303621 ❑ Manteca 823-7104 ❑Tracy 83548385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED Ck CASH RECEIVED BY DATE PERMIT NO. a EH 13-1i IREV.1 9 si EH 1416 \e]p JOI tO� —,1791