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f APPLICATION FOR PERMIT �' E SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA NJO (Al Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR TRO M DATE ISSUED NO /l t {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 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. VNob Address v u r City D954U0 71Lot Size2,00 X PM ' Owner's Name l�,��iL� rL Ae Address`'2�. s-.; S. K//�L n Phone Ar i Contractor Address License No. Phone TYPE OF WELL/PIP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public r ❑ Other 1 ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Sea] Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 UrI Depth Filler Material (Below 501 U TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO INo septic system permitted if public sewer is t _ —available within 200 feet.) Installation will serve: Residence 1 Commercial_ Other Number of living units: Number of bedrooms Y,� Character of soil to a depth of 3 feet: ` Weir table th SEPTIC TANK ❑ Typ /Mfg Capaci k. No. Compartme PKG. TREATMENT PLT. ❑ I ` Met od of Disposal Distan to nearest: W II r undation r Property Li e LEACHING LINE ❑ No. & Le th of lines otal I gth/size FILTER BED ❑ Distance t nearest: ell Foundation roperty Lin SEEPAGE PITS ❑ Depth ize Number ;j SUMPS, ❑ Distance to_ nea st: ell on Property Line ! DISPOSAL PON_DS N❑ a I hereby certify that•I have prepared this applicatio a d.that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Healt 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,I shall employ persons subject to workman's compensa- tion laws of'California. I The applicant-must all for all requi a inspections. Complete drawing an reverse side. fj �5igned Title:[J w lVE� Date: FOR DEPARTMENT USE ONLY f Application Accepted byDL ry Date 2� Area Pit or Grout Inspection by Date Final Inspection by Date ' Additional Comments: I ,�5 -� kA e ❑ Stk 466-6781 ❑ Lddi -3621 ❑ Manteca 823-7104: ❑ Tracy 835 I� Applicant- Return all copies to: Environinental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Pri'G/ 1 FEI CK E INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. I � + EH 13"24 fREV.F/851 l' ,9 CT EH 14-26 t