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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTI ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. ,/' Job Address '12g JZ 6� 4/rl4A) City N Lot Size L1"�G PM Owner's Name '17At//D C,4AI&t—I^f _ Address +�7" 2 N CGELd'�A Phone Contractor FL-0 VD 6•• & ge X2 -Address 60-5 .V. J_)"/A Al /rte License No- Phone V4-r-31?7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I 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 ❑ Other ❑ Delta Depth of Grout Seal Type.,6f'Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work.Done ❑ Type,of Pump H.P. State Work Done Well Destruction 41 ❑ Well Diameter Sealing Material (top 501 y Depth Filler Material (Below 501 aC} TYPE OF SEPTIC WORK:,,NEW INSTALLATION Ir REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is .4", available within 200 feet.) Installation will serve: Residence�" Commercial_ Other t Number of living units: Number of bedrooms 4 Lr4 9 Character of soil to a depth of 3 feet:Q� -Water table depth � p SEPTIC TANK P""Type/Mfg L'e " � `� Capacity ®r No. Compartments �— PKG. TREATMENT PLT. Elf2 x Method of Disposal Z s Distance to nearest: Well 700£ Foundation I £Property Line 1404/ .' t LEACHING LINE No. & Length of lines RS' - - Total length/size FILTER BED ❑ Distance to nearest: Well Foundation 1�)� Property Line ZfJ` SEEPAGE PITS Depth V--:; 'f Size JleO Number SUMPS ❑ Distance to nearest: Welles Foundation /AW Property Line /O DISPOSAL PONDS, R ❑ 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 rules and regulations of.the San Joaquin Local Health.District. Home owner or licensed agent's signature certifies the fallowing: "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 cert'rfies the foltowing: "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:',, j The applicant must call for all re uired inspections omplete drawing on re erre side. Signed' W Title: ' Date: � FOR DEPARTMENT USE ONLY Application,Acceptte by Date Area Pit or Grout Inspection by Date Final Inspection by DatejL_jr� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 J PEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. INFO + EH13-241AEv.i/e 5) �s-0 o igSJp /sf s$ 8'a--90 EH 10.26 � i