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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT (( � 1601 E. HAZELTON AVE., STOCKTON, CA J Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED CC (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. //�� ], c Job Address '07 �' 4J,r_s°'� `-CJ�tY City J��K 1a"/ Lot Size PM Owner's Name'o� .UAySe ✓ Address �'�^'� Phone Z099y� ZBy� Contractor G u� fl–ML. � c Address Zees E• MXa T't c�s License No. J/2ZG8 Phone TYPE OF WELL/PUMP: NEW WELL£r</ WELL REPLACEMENT ❑ DESTRUCTION ❑ D PUMP INSTALLATION C3 SYSTEM REPAIR ❑ OTHER X BoA.,rnll DISTANCE TO NEAREST: SEPTIC TANK /yA — SEWER LINES Al DISPOSAL FLD. k,4 PROP. LINE✓✓2Of-� FOUNDATION AGRICULTURE WELL ��" OTHER WELL PITS/SUMPS �R CJ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'1 Public l:1 Other n Delta Depth of Grout Seal Type of Grout _ I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ TT pe of Pump H.P. State Work Done _ -wen Destruction Destruction Fd �'e of G `0 9 Sealing Material (top 501 CC', ',r To,..f Depth 3d) 'Cr Filler Material (Below 501 �114 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permuted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS O Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 shall employ persons subject to workman's compensa- tion laws of California." The appli0,_ t call for all required ins ctions. Complete drawing on reverse side. � �� Signed X . 26 Title:Title: �C./r �CatoflJT" Date: FOR DEPARTMENT USE ONLY Application Accepted by Q t Date AreaIt -� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6.781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK t RECEIVED BYD E PERMIT NO. INFO �Q �ACASH . EH 112 111EV.ri S) _00 _V L // 7i EH 1420 "LL