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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 permlt 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.' ) 5M�E Af ,rte 1 Job Address 115-2-0 ir>T`CrMa l' ILC" RD - City 16, Lot Size PM Owner's NameytL 1�-EmN hwt-j A Address 13_1 Phone Contractor's Name 113Y 0viNui12 License No. Phone 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS} INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C 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 of Grout__ 1. _1 ❑ Irrigation —Approx. Depth El Eastern Surfacey5eal Installed by w Repair Work Done ::L_Type of Pump, —H.P. ___ State Work Done Well Destruction ❑ Well Diameter I2 Sealing Material-Itop.501_r_ Depth Filler Material.l6e6W 50'!_ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer available within 200 feet.) Installation will serve: Residence— Commercial_' Otherfflg!! NONl6PAQK, / (F Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK K Type/Mfg7-LC{dCQEM' Capacity%1W GRI. No. Compartments �- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation _ Property Line LEACHING LINE ❑ No. & Length of lines _,. Total length/size_ X3� FILTER BED K Distance to nearest: Well low_ Foundation-10 Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ft Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 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 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 shell employ persons subject to workman's compensa- tion laws of California." The applican ust c I for Al required inspections. Complete drawing on reverse side. Signed X_. Title: A&X- Date: n DOR DEPARTMENT USE ONLY Application Accepted /te47- e Date .30-944 Area Pit or Grout Inspection y Date Final inspection b Date /3 Additional Comments: C Stk 486-6781 ❑ Lodi 369-3621 ❑ Manteca 8223-7104 171 Tracy 835-M Applicant - Return all copies to: Environmental Health Permit/Se'r'vices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. FH;; (REV. ,oisal '�t S . r � LX01 g L4 19 LA3