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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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / /^ Job Address //71�77/rf 6/^L/A��G City.�L Lot Size PM Owner's Name 4�`yriC rras-AC 4 �?t j Address q I:I l7 t— S 4- 1,Y)i0d e-S-16 Phone (� !� v Contractor Ytit2Vi*MC(!- LIIIlrS r areddress License No.3f�43 phoned"35`JJ6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ,- PUMP INSTALLATION ❑ SYSTEM REPAIR' OTHER 10cP6Aljp1 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 a- ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- 5' Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seat —'— Type of Grout )1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 1 Depth Filler Material (Below 501 \ TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION t I DESTRUCTION [ 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms J Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments \� PKG. TREATMENT PLT. ❑ Method of Disposal M ® Distance to nearest: Well Foundation Property Line (� !.� 1 LEACHING LINE ❑ No. & Length of lines Total length/size 7..f. FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number l� SUMPS Ll 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, an rules and regulations of the San Joaquin Local Health DRtrict. \ Home owner or licensed agent's signature certifies the following: A 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, I shall employ persons subject to workman's compensa- tion laws of California." Theapplic`�nt��us�call for all w inspections. Complete drawing on reverse side./`� � � _/ � f� Signed X V I .[12GrZ,P�.r Title: E.-GrLf3 e_t- 40-C, — Date: Date: 4 — ro—3 /�(�� F DEPARTMENT USE ONLY fig, Application Accepted by wt c.-. �� Tia._ Date "71 6 V Area 1 _ Pit or Grout Inspection by�z Date Final Inspection by i Y� Date. � Additional Comments: J^f_� ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 623-7106 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMO T DUE AMOUNT REMITTED I CASH RECEIVED BY 'y�(( �C DATE r�PERMIT NO. EH 1}N IREV.fixsl 1 / (0q yt,t II' EH 142E