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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTn ' 1601 E. HAZELTON 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. Job Address —... 30`x}�` ~/�.Ci ✓L�.. City !e44:4 Lot Size PM • 1 Owner's Name Address Phone Contractor /"'4:;/ C`2 Address— C�,:—�`d y /+�?�,C3T_License No.r �6-$� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑, _ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .DISPbSAL.FLD -N•A PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL Y PITS/SUMPS INTENDED USE TYPE OF WELL PRQBLEM 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 EI Ot dr "' 'Delta Depth 6f Giout Seal ❑ Irrigation L--Approx. Depth ❑ Eastern Surface Seal Installed by { Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter �Sealing Material (top 501 1 I Depth ' `'" `'`Filler Material (Below 501 TYPE OF SEPTIC WORK: ',NEW INSTALLATION ~,"REPAIR/ADDITION ❑ DESTRUCTION El (No septic system permitted if public sewer is }", available withih 200 teet,l Installation will serve: Residence Commercial� Other °+t " Number of living units: Number of bedrooms_� f Y r Character of soil to a depth of 3 feet: or A Po3 -f- - Water.table.depthld SEPTIC TANK ❑j Type/Mfg ! Capacity /4�G�p No. Compartment`'s 4L PKG. TREATMENT PLT- ❑ - Method of Disposal i t Distance IoFnearest:,;F Well * Prope',rty Line__�1 d i 1 .- ouridatbn •1'_ � +` a y, � i LEACHING LINE No. & L�enth of lines _._ Q Total length/size FILTER BED Distance to nearest: Well•"f�/f Foundation Property Line SEEPAGE PITS ❑ Depth ie" $izeNumber + 1 i i SUMPS ElDistance'to`nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ I hereby certify that I have prepared this application Viand that ttWwork will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Loca(THealth 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 Inot employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring ar 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." { { l The applicant must call for all qui inspections. Complete drawing on reverse side. � ; x � Signed X r5 Title: Date FdFll DEPARTMENT USE ONLY Application Accepted by CAJ Date !' Area - t - Pit or Grout Inspection by } Date Final Inspection by. f Data :Z--k Additional Comments: t ❑ Stk'-466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 Applicant- Return all copies.to: Environmental Health Permit/Services 1601 E\HHazelton Ave., P.O. Box 2009, Stk., CA 95201 i � d FEE i INFO . AMOUNT DUE "AMOUNT REMITTED CASH 4 RECEIVED BY DATE PERMIT'No. +EH 13-24 IREV_1 i x sl._ EH 1426