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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 9 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Wealth District for a permit to construct and/or install the work herein described.This application i5 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. t Job Address City " Lot Size PM Owner's Name —&t—A-4Address � Phone 77 3RZ3 JE �yCr Contractor cL.�--Address �' g�V License No., ll—Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 17 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ n OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSALPROP. LINE h FOUNDATION AGRICULTURE WELL OTHE FLO. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA�CONSTRU PECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca o Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing - Specifications Fl Public ❑ Other t elta Depth of Grout Seal ry Type of Grout .— I I Irrigation _..Approx.- t 1 Eastern Surface Seal Installed by . ` - Repair Work Done ❑ Type mp H.P. State Work Done t Well Destruction ❑ ell Diameter Sealing Material (top 501 �t t f Depth r¢ Filler Material (Below 50 � Q TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 ,REPAIR/AD DITIONY DESTRUCTION I 1 1No septic system permilted�if public sewer is available within 200 feet.) � Installation will serve: Residence X_ Commercial_ Other Number of living units: _�— Number of bedrooms-_--r• L ' { Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments' r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ' Well �—Foandation'"'"`/P _ Properfy Line LEACHING LINE No. & Length of lines I " Total length/size FILTER BED at Distance to nearest: Well"`f Foundation Property Line - SEEPAGE PITS ; Depth I Size— 'Z -_ Number SUMPS @� Distance to nearest:. Well:A&_ Fouridifion _+1 ._...._ Property Line DISPOSAL PONDS ❑ # f 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 l 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,1 shall employ persons subject to workman's compensa- tion laws of Calif rnia." + The applicant st call for all requir ins tions:.Complete drawing on re se si e.. Signed Title: 01 Date: FOR DEPARTMENT USE ONLY Application Accepted by t Date Z Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 0 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 FEEAMOUNT DUE AMOUNT REMITTED Cy RECEIVED BY DATE PERMIT NO. INFO i `: ISS a.EH 13-24(HEY. EH 14-29