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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT IJ 1601 E. HAZELTON AVE., STOCKTON, CA 1 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 907 C-eis(-S 6w (K)Pty City S/e)C,e ram Lot Size p PM -of A o^/ Owner's NameSAddress �MMa Phone 'Z(39)/y/-,Z8y/ Contractor cc.T�t___ I,— c. Address 282S—E. ^1X LrCc S7 License No. :;-122,G8 Phone zoo y� -87/L TYPE OF WELL/PUMP: NEW-WELL 4;L,, WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK NIM SEWER LINES Nlq DISPOSAL FLD. N4 PROP. LINE 20� FOUNDATION /114 AGRICULTURE WELL X11_ OTHER WELL A64_ PITS/SUMPS A61-4 (� 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 "1 Public h: Other 17l Delta Depth of Grout Seal Type of Grout I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by nC,44,r4 Repair Work Done Ll TT� e,...off Pump H.P. State Work Done _ -Ytttl Destruction filet 1 ameter G `,� Sealing Material (top 501 CC,.-&v, 11Depth 3o FT Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted 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 C LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 shall employ persons subject to workman's compensa- tion laws of California." _ hS The appli nt mu t call for all required ins ctions. Complete drawing on reverse side./ c Sc� Signed X �- �' �!� Title: ��• r`cl 6tlC-0 1 f Date: /,L/J /- FOR DEPARTMENT USE ONLY Application Accepted by << L � Date � � Area Pit or Grout Inspection by a 4 e4QDate Final Inspection by W Date Additional Comments: C ❑ Sic t - Rat urn ❑ Lodi 369.on ❑ Manteca Servic s ❑ 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 tt RECEIVED 8Y D TE PERMIT NO. INFO /CASH . EH 13-241REV.1/45) C-00 EH 14-26 `L i