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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ,PERMIT EXPIRES 1YEAR FROM DATE ISSUED t (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. y Job Address 7sLot Size PM Owner's Name 'Fc ec7___/'/(/ /jy rte.yx(Address Phone ! S 3 Z LDa Conlraclar U C✓ t � 1e- � Address`5' �C?rc C �1trE� 2"License No��S��`/ Phane�L23- I TYPE OF WELI. PUMP:: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION ❑i. l PUMP INSTALLATION LlSYSTEM REPAIR .❑ OTHER E-1DISTANCE 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 ED Open Bottom CJ Manteca Dia. of Well Excavation Dia. of Well Casing _ t i ❑ Domestic/Private { ❑ Gravel Pack ❑ Tracy ,Type of Casing Specifications f l Public ❑ Other I ❑ Delta. l��Depth of Grout Seal Type of Grout I Irrigation _ Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump S H.P. State Work Done El _ t a. V t Well Destruction ' Wel! Diameter 1 Sealing Material f tup 50'1 f Depth I Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION FAQ REPAIR/ADDITION I I DESTRUCTION I I (No septic systern permitted if public sewer is C I available within 2W feet.1 'Installation will serve:' Residence lCommerciaf__)L Other ,Number of living units:_� Number of bedrooms P ;Character of soil to a depth of 3 feet: 4,. Water table depth _ SEPTIC TANK r ❑ Type/Mfg 7 a acit _/_CsQl No. Compartments PKG. TREATMENT PLT: ❑ 1 1,t..__ / Method of Disp9sal � Distance to nearest: Well—zS— Foundation Property Line V19 LEACHING LINE + ❑ No. & Length of lines � r r ��..- �� Total length/sire- FILTER BED E ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size — Number SUMPS L'I . Distance to nearest: Well Foundation Property Line_ t DISPOSAL PONDS ❑ j I hereby certify that I have prepared this application and that the work will be done in accordance=wi"h San Joaquin county ordinances, state laws, an I rules and regulations of:the San Joaquin Local Health District, 1 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, I shall no 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 applic ust call•for.all required inspections. Complete drawing on reverse side. Signed __ Title:'�eh �t=CYLr ►T.tc "v- ate Slee _./3t ;Y�/%•`rej�S—:S:1`�»is FOR DEP_ t_ ARTMENT USE ONLY I App nation Accepted by Date' `� A/Alirea Pit or`Grout Inspectiori by FiPat Inspection by .�� Date �r ✓ Additional Comments:'��r /rl !, �� /AYIU ati ®D 040, ❑Stk 466=6781`---'-D--Lodi-369-3E6f1 — C Mahti3ca-823=7104 -0'Tiscy'835-6385_ Applicant rmit Return all copies to: Environmental Health Pe /Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4d A FEE AMOUNT DUE AMOUNT REMITTED / V" INFO RECEIVED BY DATE T N0Em 13-24 . •.EH 11 2d tflfV.1/8 51 �� L ,