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4, L Ip AFtICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT R3- 14013 - 0 1 1601 E. HAZEL i ON AVE., STOCKTON, CA 5 Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (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. ifff N SIT ~^ 1k 4 L Job Address Islaf d_sl+ �� 0i �dL�ot Size PM �y � Or. �7 Phone v Owner's Name U.>( 1rQ''f � U -4 � Address �• Contractor Address 2.13Z5"6, A-fr'11`2 License No. 51 ZZG b _Phone �CO s 91 It TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION I1 SYSTEM REPAIR ❑ OTHER D( I�gp+GG Q�tngS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES > _ O�O' DISPOSAL FLD. PROP. LINE �Vl 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR06LEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of We*Excavation Dia. of Well Casing Type El Domestic/Private ❑ Gravel Pack, ❑ TTracy Yp of Casing Specifications I'1 Public ❑ Other ❑ Delta Depth of Grout Seal VF7Type of Grout J� I G I I Irrigation Approx., Coati = Depth { 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destfuction ❑ Well Diameter Sealing Material (top 501 f Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION CI REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is {� available within 200 feet.) ' U Installation will serve: Residence_ Commercial_ Other j Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: . Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth I Size Number t SUMPS Ll Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ z 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 I rules and regulations of the San Joaquin Local Health District. y I '. Home owner or licensed agent's signature certifies the following: "!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 applicat call for all require in ctions. Complete drawing on reverse side. u Signed X Title: Dais: /I/DU FOR EPARTfNENT USE ONLY _ Application Accepted by Date . Area ' Pit or Grout Inspection by Date Final Inspection by Date/ Additional Comments: ❑ S1k 466-6781 ❑ Lod! 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 AMOUNT AMOUNT RE TIED CASH RECEIVED BY DATE PERMIT'NO. ( INFO r, 4 r.EH 13-24(REV.i/nay U rt � �C_ V '��`q6 q " {6 EH 14-2r341