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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7'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. / Q Job Address /3`� 10 / "�' E,i/, x/61 /(/14-�p(�/� c/ciitty Z04 Lot Size' 2x PM- �.. Owner's Name 5-�e ll� L-r/ xC. /Addddr_essss ///3 ✓' ,L/ LL /dl;!f5 Phone Contractor Address Y'(L/Y� / J� !n/1 License No. Phone 1. 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 _ 1. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ff Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other n Delta Depth of Grout Seal Type of Grout_. 1 I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') W Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION I DESTRUCTION I I INo septic system permitted if public sewer is �X/ available within 200 feet.) C Installation will serve: Residence t'_ Commercial_ Other Number of living units: -4— Number of bedroo Character of soil to a depth of 3 feet: - Water table depth r_ SEPTIC TANK %I Type/Mfg Capacity �o No. Compartments PKG. TREATMENT PLT. ❑"` Method offDiispgSal - Distance to nearest: Well dee t'� Foundation�� Property Line f o LEACHING UNE No. & Length of lines o� tal length/size FILTER BED ❑ Distance to nearest: W 1/66�f Foundation 2 Property Line SEEPAGE PITS I I Depth Size 2 r Number .Z SUMPS K Distance to nearest: Web/S'© Foundation /74qlt� Property Line��'•. DISPOSAL PONDS ❑ I hereby certify that 1 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." Contractors hiring or sub-contrapting 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 appli n St r r �I ctions/�o tete drawing on reverse side. Q Signed X�S1� µ;� Prc/ '/ l�`Ln//r'dr/L Title: �/,T/[�/✓ Date: -�z�0 l DEPARTMENT USE ONLY C1q A ication Accepted by �L�4i+.r__1 Date C( Z-V L Area � t r u y Date Final Inspection by Date �� r S/ O dition.1 Comments: ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-Ub4 A TWy 835-6385 .. Applicant - Return all copies to: Environmental Heath Per ' / ices 1601 E. Haz on Ave., P.O. Box 2009, Stk., CA 95201, INFOFEE OAMOUNT AMOUNT REMITTED CASH RECEIVE BY DATE PERMIT NO. ' EH 14 MIREV.1/x5i �] ��