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M APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTONhAVE., STOCKTON, CA Telephone 12091 466-6781 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L {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 Ryles and Regulations of the San Joaquin Local Health District. Job Address 14'90 Wim" JL6CC Er—6 ab S"_': City Lot Size '140 X 1605" PM c—=1 lSfE il' H+2131A1,Di M �.rr' e y Owner's Name NI A, el)tl Address y E� G P_ t I VFX C�f�E+` 1 Phone t j� Contractor L' Address License No. Phone�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION)< PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ !x "OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAk"FLD. PROP. LINE FOUNDATION AGRICULTURE"WELL_=; OTHER WEL"L"' PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA `CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ofWell.Excavation f--e Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing —f—' ' Specifications ❑ Public ❑ Other Ll Delta I Depth of Grout Seal Type of Grout ❑ Irrigation __4pprox. Depth ❑ Eastern Surface Seal Installed by p_-i Repair Work Dane ❑ Type of Pump H.P. # State Work Done Well Destruction ❑ Well Diameter Sealing Material-itop-WI—"•� $ 4 Depth Filler Material iBelow 501 iii v O l OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer available within 200 feet.) Installation will Residence_ Commercial_ Other f Number of living units: umber of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ "Type/Mfg Capacity f No. Compartments PKG. TREATMENT PLT".-M-- Method of Disposal Distance.to nearest: Well '• �F-' :onProperty Line LEACHING LINE i ❑. �9,No.& Length,of lines Tota h/size FILTER BED ❑r Distance':to nearest: Well. - Foundation Prope I SEEPAGE PITS r ❑ Dep't'h ) Size Number I, SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS E -" " 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."Contractors 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 applican call for II'required inspections. Complete drawing on reverse side. r Signed Title: d4ffl.Lbw Date: 1�2 `6 FOR DEPARTM T USE ONLY r Application Accepted by Date �a2 r0 Area 17— Pit or Grout Inspection by Date Final Inspection by ate 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., P.O. Box 2009, Stk., CA 95201 FEE r INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY; DATE PERMIT"NO. i + EH 13-24(REV.7/a 51 ,," EH 14.26 ( VV