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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZEL T ON AVE., STOCKTON, CA ; Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thework 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 �! 8 Q '" City /� Lot Size /07 91 �G. PM ,�j h Owner's Name Kis I 1 k JZPA�eti-_ Address c$ Phone jEig?_ Contractor INFO! Address License No. Phone TYPE OF WELT./PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ # DISTANCE TO NEAREST: SEPTIC TANK- SEWER"L'INES '` DISPOSAL FL"D. '"'L PROP. LINE-, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS",— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca"kV�.,-Dia. of-,Well Excavation Dia. of-tWell�Casing ❑Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing' Specificationsv 1A Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout i Irrigation __Approx';Depth l I Eastern 'Surface Seal Installed by - } Repair Work Done 0 Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth i Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION _ REPAIR/ADDITION l 1 DESTRUCTIO_NI I Wo septic system p6rmitted if public sewer is ,available within 200 feet.) t Installation will serve: Residers'ce_ Commercial_ Other ' r �' Number of living units: Number of bedrooms - _ fa It f r Character of soil to a depth/of 3 feet: *` --- -= Water table depth SEPTIC TANK ❑ Type/Mfg 'f �. �lt�c H� z Capacity 1,4000 No. Compartments , PKG. TREATMENT PLT. ❑ -a - wr L= Method of Disposal _ r Distance toen arest: Well - J Foundation-Al Pfnperty Line LEACHING LINE ❑ ' No. & Length of lines FILTER BED © Distance to nearest:f�;.l Well d Fobdation Property Line SEEPAGE PITS I I DepthSi2e ll i`. / Number SUMPS L�1 Distance to}nearest �'1 Wellk Foundation Property Line DISPOSAL PONDS ❑ t. I hereby cerflfy that I have prepared this�ppi6iion`:and that the wbiZ'W l`U done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin?Local Fies'Ith Diktrict. ? y- L t Home owner or licensed agent's signature,'certifias jhe following: "I certify"that iiin,,the performance of the workffor which this permit is issued, l shall not x e aroloy any person in such rnanne`r•as ib.becorne subject to workman's compensation laws of California."Contractor's hiring or stab-contracting signature t certifies thi.1otlowing: "I certri V•that in th'etiperformahce of the work for which this rrjit,is issued, I shall employ persons subject to workman's compensa- tion laws of California." ( The applicTmust call for all rQquired ltt fictions>{Gomplete drawing on reverse side. Signed Title / � ifi lr _ _ Date: FOR DEPA MENT USE ONLY /� Application Accepted by '»�t'� �'� �- Date Araa l _ I Date t ` Final Inspection b Date 1r Pit or Grout Inspection by P Y � - i S�a41 � \ i Additional Comments: ; - - °❑ Stk 466-6781 ❑ I;odi, 369-36� i ❑-Manteca 823-7104 0 Tracy 635-6385 iApplicant - Return all copietsp to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE AMOUNT DUE AMOU�NT REMITTED CASH RECEIVED BY DATE PERMIT'NO. _-,....,::.....�......�,... I NF_p �/f I ��j +.EH 13-21(REV.t i n 5) - --�- --r7 D /1'J�].._._ �/�p'�P�P.Y t r 3 EH 14-29