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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. 1861 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address J 70 0 Q f1NE rRSE Q bf� city E sc.v[—406/Lot Size, a h CK t S PM J Owner's Name tPJSE weGC At Address Jam'/� 0 •[J 0K 1177 67SCA eM — C? ;t Contractor 11 u)Ale Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r 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 ❑ 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 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 0 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION'❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 2(10 feet.) Installation will serve: Residence—/Commercial_ Other r Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: _ Water table depth a SEPTIC TANK ❑ Type/Mfg Capacity 1aDO No. Compartments PKG. TREATMENT PLT. ❑ _1k Method of Disposal (� Distance t6 nearest: Well /0 /QO f Foundafrori Property Line /oro{` LEACHING LINE - 14 No. & Length of lines �- /DO r 1!G Total length/size o?00 (ty FILTER BED .Distance to nearest: Well i r ` . _ �-� Foundation ->•� Property Line .�. SEEPAGE PITS 9"Depth !O' Size- g X to Number 2 SUMPS - —Distance to nearest: Well /. 9774 Foundation *00' Property Line 0 / DISPOSAL PONDS ❑ 50Mv nl(7- TD 5mo 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: "1 certify that in the performance of the work-for which.ihis 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-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 j� sst�niil for I reeqn�ui�red inspections. Complete drawing oreverse side. Signed X -UG7� lN ��-� Title:Vii! Date: //�� FOR DEPARTMENT USE ONLY Application Accepted bv & XJ Date 6 Area ©4�p �,P Pit or Grout Inspection by Date Final Inspection by Date A v 7 a Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3627 AMantecia BM-7104 ❑ Tracy 835.83% 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 ASH!!{{ RECEIVED BY -DATE PERMIT''Nb. EH 13 24 r;051 /(� o -7 eU EH 1328