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C_00 C{'Z APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T 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. n V Aar/"c'1 Job Address 1e'sOOt? Wowoe,y A�efgrG�•y City T�-e�,�_ Lot Size PM Owner's Name .A4,r F4�A�t'. Address Phone Contractor /QAo, q(3-1A.- Address 100-0 &ve v"? License No.W�01V Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 F'1 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation .Appr ox. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material.(top 50'): 0 Depth Filler Material (Below 501 0 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is 0 available within 200 feet.) U Installation will serve: 'Residence_/_ Commercial_ Other Number of living units: _/— Number of bedrooms Character of soil to a depth of 3 feet: C40-41Y L0.014f Water table depth 10 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well _ Foundation /0 Property Line S� LEACHING LINE No. & Length of lines tT Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ 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 j 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 rA 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 applicant m t all for all required inspections. Complete drawing on reverse side. Signed X Title: Date: 3-lG FOR PEPARTMENT USE ONLY Application Accepted by ' Date I Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,'PI.0. Box 2009,Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATEPERMIT NO. INFO /� + EH 13-24IREV.1i95l EH 11-28 �%/\O `0o \"_ — 5