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APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATEISSUED No�0 5�6 _l� : (Complete in Triplicate) e r� 46 1 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. 1 Job Address - 1/�� i�✓G 'IlAr S7101,-<7— ` City �ot Size- PM C r1y,JA142 o2 A-,Vo I C r Owner's Name 45lNI40677�� rAt � 7 Z+C// -7 ` S Phone Contractor �EL Address License No. Phony_ I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 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 N t ❑ Industrial ❑ Open Bottom L1 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public n Other f Cl Delta Depth of Grout Seal Type of Grout _ I i Irrigation a .Approx.[Depth l I Eastern Surface Seal Installed by Q1 Repair Work Done El Type of Pump 'H.P. State Work Done Well Destruction ❑ Well Diameterr Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I7 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence_I Commercial_ Other Number of living units:' Number of bedrooms r > Character of soil to a depth of 3'feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ' Foundation Property.Line 1 LEACHING LINE. ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line. SEEPAGE PITS C I Depth r Size Number a SUMPS Ll Distance to nearest: i Well Foundation Property Line DISPOSAL PONDS ❑ l 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 t 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: 1 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." r The applicant st call for all required inspections. Complete drawing on reverse side. Signed X r_ Title: Date: i ANENT USE ONLY [��`[� 3, Application Accepted by OAA, Date ✓� Area - t Pit or Grout Inspection by Date Final Inspection by Date �2 Additional Comments: B' D Z-K3 SR ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Man eca 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 CK 0 INFE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13.241REV.I/nsl ' EH t4-2t1 [ d� �+t(�/ (,�fV00 l 'n