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c; { APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (249) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEW (Complete in Triplicate) ,,:K, 1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereiri described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health Diitrict. t s c4 Job Address TIq �� f City 4GK Lot'Sue PM y Owner's Name FDSTE Q l fi?N 9 R IZ. Address M F – Phone- Q0�ontr ctor d License No. p ddress �� O X �`] a Phone D TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP.INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ E DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS ..r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑e Gravel Pack Ei Tracy Type of Casing 'Spa ifications ❑ Public ❑.Other ❑ Delta Depth of•Grout Seal Type of Grout ❑ Irrigation ---Approx. Deptlll ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. WD State Work one Al F 7- ' v P Well Destruction ❑ Well Diameter. Sealing Material (top 50') I�7CE F IP U-0 . Depth Filler Material (Below 50') 3 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: � Number of bedrooms �a FI Character of soil to a depth of 3 feet: 1 r ater table depth 9� IX SEPTIC TANK ❑ Type/Mfg Capacityr vy Np. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ;Well Foundation Property Line ri i r l f ! I f LEACHING LINE ❑ No. & Length of lines Total length/size V : FILTER BED ClDistance to nearest: ,Well Foundation Property Line ! SEEPAGE PITS ❑ 'r Depth` °a !'Size timber ' SUMPS ❑ Distance to nearest: Well Foundatiah-, Propert Line _ .- DISPOSAL PONDS i ❑ ti '• I hereby certify that I have prbpared this application and that the work will be d 6ne in accordance with San Joaquin county-ordinances, state laws,.and {{{ rules and regulations of the San Joaquin Local Health District. ,y ! Home owner or licensed agent's signature certifies the following: "I certify that 1n 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`daws bf California."Contractor's hiring or sub-contrtacting 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." 11 �, !! The applicant I r all r it inspections. Complete drawing on/rev`r side t Signed - '. Title �V 4'rV �/�/� ]� Q FOR D ARTMENT USE ONLY \ ,r � Application Accepted by '� Hate —� ea / t: Pit or Grout Inspection by '� Date Final Inspection by ate j z ' I Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C IC% r Q t r*t FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE -PE IT`NO. INFO CASH + EH 13-24 1REV.1/s 5] _�3 C O - "- +- "' ` 5-S 4 obb EH 1426