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"APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6761 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 AddressS,5-73 W. 4{1x W4 Gity !' Lot Size PM Owner's Name f� i Address S CV. � G Phone Contract Address_)eo• ��` 71 r 3Zd Z� Phone JSfO s !License No_ TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAR T. SEPTIC TANK SEWER LINES DISPOSAL FLD_ PROP. LINE W FOUNDATION AGRI L OTHER WELL PITS/SUMPS INTENDED i1SE TYPE.OF WELL PROBLEM AREA CONSTRUCTION 5 TIONS ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia_ of Well Casing ❑ Domestic/Private ❑Gravel Pack' ❑ Tracy Type of Cas( S bora ❑ Public ❑Other ❑ Delta Depth of Grout Seat 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 50') Depth Filler Material(Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION X, REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is =table within 200 feet.) Installation will serve: Residence_ Commercial, Other Q,g-6. Number of living units: Number of rooms ` Wa-0 / Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK &3--Type/Mfg Capacity_/&QQ.` No. Compartments PKG. TREATMENT PLT_❑ / / Method of Di I Distance to nearest: Well�DO Foundation Property Line LEACHING LINE & Length of lines Total length/size © X FILTER BED ❑ Distance to nearest: Well 0�00 , Foundation �_6 1, Property Line S r SEEPAGE PITS ❑ Depth Size _ Number SUMPS ❑ 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, and rules and regulations of the San Joaquin Local Health District. 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 mariner 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 applicant can for all wired inspections. Complete drawing on761718 �} Signed Title: . Date: - 9 QidA, FOR DEPARTMENT USE ONLY Z f{ Application AcceptedA 4v by �jC/`n! Pate �� 7 Area 7 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-5781 ❑ Lodi 369-3621 ❑ Manteca 8237104 ❑ Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave_, P.O, Sox 2009, Stk., CA 955201 �4V INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. i9111 n . I /) /1 I I I I - 1