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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT -/ 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1Complete 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 6 ! � el,r kne- ��O!/� /r City C. O �?! r Lot Size 5" 2 Ae— PM Owner's Name y4r',7LA40-15 �o L1 S .IC Address 7 �k �N 111P� , srK Phone '— Contractor's Name /JJ C C0,0 ST %A -"G License No,1Z.2 13g6 301 RECEIVED BY phos TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ S`' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE `3 `k 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 Deptli of Grout Seal Type of Grout ❑ Irrigation --- 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 Depth Filler Material (Below 601 _ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.} Installation will serve: Residence _ Commercial _ Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK i -k Type/Mfg C0:—c—g--n1enapacity12—n c_ No. Compartments PKG. TRE4TMENT PLT. ❑ Method ofDisposal Distance to nearest: Well A29 4- Foundation /a Property Line LEACHING LINE No. & Length of lines _ Total length/size !� FILTER BED ❑ Distance to nearest: Welly_ Foundation /d!D 'r Property Line �"' � z SEEPAGE PITS Depth Size 2 Number SUMPS ❑ Distance to nearest: Well/jam sem_ Foundation Zb f Property Line DISPOSAL PONDS ❑ nereoy cert fry 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." The applio//Gust call or I required inspec " s nplete drawing on reverse side. Signed �W9 g _. Title: vo !?_ S �� C C Date: oZ l g FOR DEPARTMENT USE ONLY 7 _ } Application Accepted by % �j Date S 4 Area d f qr Grout Inspection by y Date— ' Z incl Irtspecti in by �i Date Additional Comments: r !� ❑ Stk 466.6781 �Lodi..369 3621 ❑ Manteca 823 7104 ❑Tracy 835 6385 Applicant - Return all onvironmental Health Permit/Services 1601 E. Hazelton Ave., P.0_ Box 2009, Stk., CA 95201 + EH 1324 (FIEV. 10183) EH 1428 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT N0. LZ `�� S`' Sol (0 N Z `3 `k