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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE'LTON 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. Ze P910/2 M72, Job Address City Lot Size PM Owner's Name �d�X./ru.r.� Address ��PhZone Contractor Gt/TIJ�Q� a� - Address 39190 A/, �c}�Wo License Nn.25V_3!` �_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION CI 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 ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Belo ) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION V DESTRUCTION ❑ fNo septic system permitted H public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units:___J_ Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK hype/Mfg Capacity/aQQ 6kd No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Zoo f Foundation__fit _ Property Line LEACHING LINE ❑ No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �l 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-0istrict:"" 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." The applica ust tail(rZallreq:u�i:red ' s mplete drawing on r erre side. Signed Title: Date: FOR DEP TMEIYT USE ONLY Application Accepted by Date Area Pit or Grout Inspection b Date Final Inspection by Date �lJ prmtS /J7, rrn , I°r f9ma� 7L-n fns/414liG++i �.» /gee" 9!1_T v// Geea4,4s� "onaI Comments: tk 466 6781`` 369- ❑ Lodi 3621 C3 Manteca 823-71 13 Tracy Mgww plicant- Return all copies to::Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA " s FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'"NO. INFO + EH13-24 inEv.I/8 5) EH 14-28 �+o�