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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT w 1601 E. HAZELTON AVE., STOCKTON P;4 Y M E N T Telephone (209) 466-6781 RECEIVED p PERMIT EXPIRES 'I YEAR FROM DATE ISSUED Complete in Triplicate) A ' } Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install +��R @rim described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and 1=W6 TA&**"n Joaquin Local Health District. HWITJSERVIC 3 Job Address 19-.nW- G rarM a City 41 Lot Size 1,1$wi-e- PM 9YS66 Owner's Name 0,1i nAaen C breert L MA,0 !►ddress P38 AaV 4 D e. P["5a4nn Phone(' 15)44a--4 S ►f l ZZZ31q Contractor ? roe l�. Address o �5 `I License No.- QLicense _ hon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 ❑ 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 W Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units:—I— Number of bedrooms �� Character of soil to a depth of 3 feet: aLe, Water table depth SEPTIC TANK , Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ lff! Method of Disposal 1 Distance to nearest: ,/Well� Foundation �Q Property Line l 1 e.24 `. LEACHING LINE '19- No_ & Length of lines a Total length/size FILTER BED ;41 Distance nearest: Well./jie:!C— Foundation Property Line SEEPAGE PITS ❑ Depth Size �ilo Y10 Number <295;;11LV Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ... ❑ u I hereby certify that I have prepared this application and that the work will be done ih-accordance with San Jooaquiri--county-ordinances; state laws;•an d 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 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 applica must call:for all r.equyV inspections. Complete drawing on rev a side. Q Signed Title:_ � Date: V OR DE MENT 115E ONLY J Application Accepted by Date / Area / Pit or Grout Inspection by Date Final Inspection by Additional Comments: d Alf ❑ 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO ccc777 + EH 13-24 1REV.i i e 5) 7�, v EH 1426 LN