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r 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 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. 1882 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. 7 f J 12 Job Address city C of Siz., _� CJ1/f/�S PM Owner's Name /��UtlI e • c" Address X c+' IV t,1l �liG 34 G1�Q Phone Contractor 5 -p9 e Address License No. 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 ❑ Public---- Other,.._❑ Delta .Depth o Grout Seal R Type of Grout ❑ Irrigation .—Approx. Depth 31 C1 Eastern, Surface Seal Installed by %1K- Repair Work Done ❑ Type of Pump H.P. State Work Done W�ll Destruction El Diameter Sealing Material (top 50'1 I Depth Filler Material {Below 50') TYPE,OF SEPTIC WORK: NEW INSTALLATION JK REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 1 I 1 M U 12 �LL available within 200 feet.) instpllation will serve: Residence� Commercial— Other 4a I Ing y s Nu ber of living units:�- Number of bedrooms 2- { . Ch ratter iof§iiif to a depth of 3 feet:., I.Water table depth ` SEPTIC TAK Type/Mfg Capacity ZI[-6l9 No. Compartments PKG sT#EATMENT PLT. ❑ / Oil Method of Disposal z Distance to nearest: `Well y®� Foundation �® f Pro6erty Line r rrr 1 LEACHING LINE No. &iLerigth of lines Total length/size FILTER BED Distance to nearest: Well-b Foundation Property Line i I I SEEPAGE PITS... Depth Sizew Number I �p SUMPS Distance to near Well t- -1 0 M Foundation Property Line 1y� DISPOSAL PONDS ❑ ,, �I�t hereby certit`Vr that l have prepared thh,8pplicatiWand that the work will bedonein accordance with San Joaquin county ordinances, state laws, and rules and regulations of the 5an'Joaquin Local Health'District. + Home owner or,06ensed°agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall Trot rr employ anylperson in such manner as to become subject to workman's compensation'laws of California:i 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." ** t U The applicant 71IT83 call for all required inspe 'ons. Complete drawing on reverse side. Signed)K— �4. G`_ f Title: LC/ ti,c.� S� Date: iFOR DEP RTMENT USE ONLY" ' Application Accepted by Date l Area Q Pit or Grout Inspection byf Date Final Inspection b Date Additional Comments: r �� ❑ 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., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. °= + EH 1324(REV., e 5) LA �. Crl t� EH 1426 � �� .