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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. ��rt7� Job Address 665 mFMI I I 1 Ro city FR C' ' - Lot Size /O (�Cat'� PM Owner's Name '7:50nN CA(11 roe 1A Address 13130 CPvi �rL 7Alla— Qu/f1 igri; IYOW(16 ' 17 7 Contractor --Pm C'AR6)1--_ Address ISO dUMCi -U 'Able- License No. Zy3�1�8 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLAT ON ❑ 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 Die. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation y —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is 'p available within 200 feet.) Installation,will serve: Residence_ Commercial_ Other. Number of-living units: ( Number of Cba,B,rooms 41 Character of soil to a depth of 3 feet, Water table depth SEPTIC TANK ❑ Type/Mfg •1 Capacity Ga ew'14— No. Compartments 21 PKG. TREATMENT PLT. ❑ t Method of Disposal Distance td nearest: Well OG Foundation Property Line LEACHING LINE ❑ No. & Length of lines •c Cir Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size 10 X I 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. .V 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, 1 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." The applicant must for all required inspec ns. Complete drawing on reverse side. Signed X (//rsr " Title: ct''"WL(%-_ Date: 12 21-K FOS DEPARTMENT USE ONLY Application Accepted by /!/h/ Date R ` Area Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: ❑ Stk 4666761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 83545385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDC RECEIVED BY DATE PERMIT'NO. INFO EH 1124 (REV.vest EH W29 /V• CSO 3.3 -L �7l' 1i �7 �'- 1