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Jr� APPLICATION FOR PERMIT L SAN JOAQUIN LOCAL HEALTH DISTRICT bf 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I'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 � '� �� 'Cs 4 c�� _ ____ City ZV4f Lot Size ]� �Ra° PM Owner's Name li17t`iA b"4 3 SLr SGnrl, L Address 7'1 , .Tk—d 571 T,. Phone Contractor ('t A Address )i(2 1`t I GC�D UtS A License No. 6 Phone 1p�3> - >S TYPE OF WELL/PUMP: KEW 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 1'1 Public f_1 Other Cl Delta Depth of Grout Seal Type of Grout _ Qp I I Irrigation —Approx. Depth I i 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 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence✓ Commercial Other Number of living units: Number of bedrooms_ Character of soil to a depth of 3 feet: ! Water table depth SEPTIC TANK FE�'�Type/Mfg (fjD.,! Capacity IADO No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Weh a0 Foundation /Z)_ __ Property Line __)_D LEACHING LINE No. & Length of lines r__.�{d�L7 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth SizeX33 m &d m h,, Number SUMPS Cl Distance to nearest: Well mob Foundation �vProperty Line .10 DISPOSAL PONDS ❑ I 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 Di%trict. 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 applicant must call for all required inspections. Complete drawing on reverge side. Signed X �r p z_ � . wl Title: 1r__%1 t/�ZA Date: FOR DEPARTMENT USE ONLY 1 -7 Application Accepted by _ ! �, _ - Date Area Q Pit or Grout Inspection by r� Data Final Inspection by Date Additional Comments: 4,4 ❑ Stic 466-6781 Ef Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy -6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED Y DATE PERMIT NO. [N111 CASHEH 13-2A--W. '-rt / ( `� EH 14-26 rr