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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 9. 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Y, I (Complete in Triplicate) i 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. Job Address �!� f"' /r d�/✓"�' City SRO Lot Size PM �� }� Owner's Name 1L./. I� ��4f�.Address Ph ! � Contractor. B-77q7 ZOO* Address �G � License Na.��s PhontAAtio'n' TYPE OF WELL/PUMP: 4 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL s PROBLEM AREA CONSTRUCTIO ATIONS - I r ❑ Industria! ❑ Open Bottom ❑ Manteca Di a Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications M 1 Public, _ .,,� &.( Other " Delta Depth of Grout Seal Type of Grout I I Irrigationrox. Depth 1 i Eastern Surface Seal Installed by t Repair Work Do Type of Pump H,P. State Work Done_ r d 1 s Well coon ❑ Weli Diameter Sealing Materia! (top 50'I 3 Depth a Filler Material (Below 501 k t TYPE OF SEPTIC WORK: NEW INSTALLATION 41 EPAIR/ADDITION^ DESTRUCTION I i 1No septic system permitted if public sewer is x r `~'; available within 200 feet.) ? t � Installation will serve: Re idence Commercial_ Other Number of living units: . Number of bedrooms ` j Character of soil to a depth of 3 feet: WOE S49L& Water table depth Al SEPTIC TANK � Type/Mfg Capacity ��® No. Compartments PKG. TREATMENT PLT. ❑ ` Method of Disposal 44ro t Distance to nearest: ,. Well ,J®�Foundation� Property Line,,,Z� I LEACHING LINE No. & Length of lines " Total length/size f FILTER.BED ❑ Distance to nearest: Well Foundation Property Line t - r SEEPAGE PITS 11 Depth, Size Number y i SUMPS D Distance to nearest: Well, Foundation Property Line DISPOSAL PONDS � ❑ t s 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 I 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 4 , 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 followi ,"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 Calif a." t The applican tali all re ire ins i Complete drawing on r verse side. 1 s Signed X Title: f Date: s. FOR DEPARTMENT.USE ON Y Application Accepted by air, Date 579 ox Area I' Pit or Grout Inspection Date Final Inspection by DateY r�g t Additional Comments: [ ❑ Stk 466-6781 ❑ Lod 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 4 # Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r INFO AMOUNT DUE AMOUNT REMITTED CAK RECEIVED BY DATE PERMIT'NO. S � + EH 13-24(REV.r i n 5) I EH 14-26 lo