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2. 06 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L. 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 Regulation of the San Joaquin ` Local Health District. G�� 'e Job Address 9r(y/g m,&,� �� City � Lot Size A�, PM lim Owner's Name lZ4 Vw ��S�Ey Address l Phone jl Contractor rC4_ A SDv X Address NQ ZA"O a'""t/ License No. Phone p�60 �r 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 WellExcavationDia. of Well Casing in ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P.6. State Work Done -Well Destruction ❑ Well Diameter Sealing Material (top 50'1 ^ Depth Filler Material (Below 50'1 6` TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is ` available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: 2- Number of bedrooms ZS Character of soil to a depth of 3 feet: Water table depth `' SEPTIC TANK A Type/Mfg PO"— e_0 zC4Gf'[. Capacity/2+ aO No. Compartments PKG. TREATMENT-PLT. ❑ Method of Disposal Distance to nearest: Well Foundation rQ Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 0 SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r. 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: "1 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 t. 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 applicantm��u st call for all lrrequired �inspections. Complete drawing on/reverse side. 4 Signed X /.Nitre /•fC .C.s/I Title: C�Q.L- Date: 1 249 ti. OR DEPARTMENT USE ONLY �± Application Accepted byy V Date d Area t• Pit or Grout Inspection by Date Final Inspection by Dat *4! Additional Comments: Cl Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ` INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATEy`-[ y�Pc`ERMIT IN)O.� 4 EH life(REV.I/x 5) 0. 00 �A _ y—f3 " 1 e 1-2R.1{/ EH tela l—