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APPLICATION FOR PERMIT — `tAN JOAQUIN LOCAL HEALTH DISTRIW' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone Q091 466-6781 ybs-_3yoz 6g-3�fz� 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 Regulations of the San Joaquin Local Health District. Job Address /__._( 75 5 r—z z"Xw 1A0 `J City ES e- (�/611A Lot Size PM Owner's Name SuJe k { Address / ` rT V LV '�C� Phone Contrac%"1Ph'fPW _Adq4ssS2711 E J-fFhKgULicense N0.42J. " _Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION W 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 Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public ❑ Other Cl Delta .Depth of Grout Seal Type of Grout _ I I Irrigation _.Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done IV Type of Pump Su,6 H.P. State Work Done_ Well Destruction ❑ Well Diameter tl Sealing Material (top 50') Depth Material (Below 501 - N TYPE O� SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sewer is ' /� available within 200 feet.) v 1 Install!ltion will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth c� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments _ C PKG. TR TMENT PLT.❑ Method of Disposal �C Distance to nearest: Well Foundation Property Line N LEACHINGINE ❑ No. & Length of lines Total length/size Cj FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS II Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that Ihave 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 D3trict. 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 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applican(J(�usst call for all quirg inspections. Complete drawing on reverse side. ) Signed XLtwNINJ .b� Titlea. ( Date: ESQ PARTMENT USE ONLYApplication Accepted by6,,,,�OR /'T/�(i4_J,r,J Date �/ _ Area Pit or Grout Inspection by Date Final Inspection by Oat Additional Comments: ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH1a.628 211REV.lixsl EHi426 3S' 00 3S-- UJ 230 (p-27-AP-i 7n-/ZfPO'