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F APPLICATION FOR PERMIT SAN JOAO,UIN,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) ��V��r•-'' `�e�� ' 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 � � � �` Ct City A46CACZA, Lot Size PM Owner's Name &f t�14f Address % L67`7tiviGioJ r Phone Contractor k' �� "Address K License No.3 y�Jk_Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Cl SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LIVE FOUNDATION 'r ' AGRICULTURE WELL ' `OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO15 ❑ Industrial ❑ pen Bottom Manteca Dia. of Well Excavation Dia. of Well Casing (� Domestic/Private 'Grave! Pack ❑ Tracy Type of Casing ��T _ Specifications f ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation g417Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Cl Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION © REPAIR/ADDITION Cl DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.i" 0� Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal , _Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ,,.u❑ 'No. & Length of lines Total length/size FILTER BED "El-' 'Distance to nearest: Well Foundation Property Line >� 1 SEEPAGE PITS ❑ Depth Size Number _ = : —SUMPS ❑ Distance to"nearest: Well Foundation Property-Line DISPOSAL PONDS ❑ z 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." 4."`�--w,Y .�. The applicant m I for al eq i d ' spections. Complete drawing on reverse side. ": ,;;.;p7 Signed Title:_�" Date. FOR EPARTMENT USE ONLY Application Accepted by M Date �" Areas Pit or Grout Inspection by Dat Final Inspection by et. C;x Additional Comments: '❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354385 -�' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. INFO t eo