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APPLICATION FOR PERMIT fi SAN JOAQUIN LOCAL HEALTH DISTRICT 0 T 1933 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 F1,14i` lirvNrMEN—,AL j�Zj. TH I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES F I I (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 Juaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ff Job Address 7 1W H'Immap. City Lot Size /4000 # r PM j Owner's Name Vivo W 419s Address Phone p5 �� S s 4s��►. �c,��}' i Contractor dress 2S2 04Grf,21Eeose No. y 0 Phone S3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER EN sV OV &4.101L�r,S DISTANCE TO NEAREST: SEP RIC TAMC SEWER LINES ?/DO' DISPOSAL FLD. PROP. LINE i _FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS- —� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATqVS ❑1ndustrial ❑ Open Bottom ❑'Manteca Dia. of Well Excavation Dia. of Well Casing © DomesticlPrivate ❑ r�vel Pack ❑ Tracy Type of Casing Specifications F1 Public [�f Other 66'e*A1q Cl Delta Depth of Grout Seal Type of Grout I I Irrigation JXapprox. Depth l l Eastern Surface Seal Installed by _ \ Repair Work Done 0 Type ofII Pump H.P. State Work Done_ Well Destruction © Well Oiameter Sealing Material (tap 50') Depthl�: Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I DESTRUCTION (-]'(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 13 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Ca acit p V No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Dis onto to nearest: Well Foundation Property Line I�, LEACHING LINE ❑ No14 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line l .II. SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 4 :Property Line- DISPOSAC`PONDS' .w ❑ O i 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 sign tura certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall not 1 employ any person in such mannei a to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the follow' "I cart th{dtthe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of r o ill' The applicansl c II or I qui d inspections. C tete drawing on reverse side. Signed X title: .. '1 Date: � III FOR DEPARTMENT USE ONLY I Application Accepted by Date �� 1) Area Pit or Grout Inspection by �111 Date �U Final inspection by p'd Date , I`I s Additional Comments: I ❑ 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 AMOUNADUE AMOUNT REMITTED CASH E E 3RECEIVED BY DATPERMIT NO. j t.EH 13-21 IR EV.1/R51 S 3S Z73"�- EH 14-26 �II