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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE:., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I" (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 r 00 A Z -1W ey— _ C City Lot Size /�� w PM Owner's Name %:ICi Address + / ` e �I` /� Phone s6s, 15-2 f Contractor's Name y -c LC. � License No. Phone 34JE-3 .33 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 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 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION CYREPAIR/ADDITION ❑"DESTRUCTION=_ -[lyo-septic system -permitted if.public sewer is "F 'available within 200 feet.) Installation will serve: Residence , Commercial _ Other i �z Number of living units: -I— Number of bedro ms 1+ 0, `6 Character of soil to a depth of 3 feet: eA w- Water table depth 1>� SEPTIC TANK 9�-Type/Mfg Capacity�� No. Compartments PKG. TREATMENT PLT. ❑ S ')'' Method ofDisposal Distance to Foundation _. Property Line LEACHING LINE .[1L/6o. & Length of lines Ve F ;.# , f g Total length/size FILTER BED E Distance to nearest: Well .,:Fo ndation -a3 U Property Line SEEPAGE PITS IN -'Depth B`f;� Size- t _Number �-- 'O SUMPS El Distance tor nearest: well �� Foundationa �% N I Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work wiil'be done in accordance with San Joaquin county ordinances, state laws!and rules and regulations of the San Joaquin Local Health District:, tl 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." 3 s The applicant m ail f all q ' e inspections. Complete drawing on ice' reverse side. j ,` Signed Title: ZJAArK Date: c, moo" 3- "Qrr / FOR DEPARTMENT USE ONLY Application Accepted by Date r Pit or Grout Inspection by. Date 4Z3-E`6l.1 Final Inspection by Additional Comments:M_ GI 4A P IAD e ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 13.241REV. 10183! EH 14-26 Date T i� __A�11 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PERMIT N0. r�DATE Q 'df�U (� r10✓