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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 TYEAR FROM DATE ISSUED (Complete in Triplicate) l Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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 / 706 City X Lot Size PM Owner's Name y/7 � .�T(J �/�/y / . A2ldre s� 1 S Phone Contractor 1O21�1z Address r�`fc f? //fes �CQaC °�icense No. �� fs'�I Phone - 2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISPOSAL LO. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WE L PITSISUMPS "I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation € Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications { v 1'l Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pumpw H.P. State Work Done Well Destruction I)Rl Well Diameter l.3 Sealing Material (top-374- Depth �� ,.Filler Material�f elbwf90_ TYPE OF SEPTIC WORK:- NE=W_1NSTALLAT.ION.1:1_..REP-41RI.ADDIIIONJ~3.-..DESTRUCTION-11-IN6jseptic system permitted if p u lic sewer is Ir- available within 20p.feet.) Installation will serve: Residence_ Commercial !,Other-Y I Number of living unitis: Number of bedrooms Ll i Character of soil to a depth of 3 feet: t f 1 !' Water-table depth SEPTIC TANK ❑ Type/Mfg "1 µ_ Capacity '` -'�,. No:Compartrtments l PKG. TREATMENT PLT. ❑ Met d of Disposal� i s r I Distance to nearest: Well , Foundation . (PropertyLine fi i --a LEACHING LINE ❑ No. & Length of lines Tafal length,/size ) FILTER BED ❑ Distance to nearest: Well Foundation i Property Ina SEEPAGE PITS l I Depth size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance withan Joaquin"county ordinances, state laws, an 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 th 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.'i 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,1 shall employ persons;subject to workman's compensa- tion laws of California." = r ' F The applicant 1 f all re r spections. Complete drawing on rever ide. 1 Signed X Title: - r FOR DEPARTMENT USE ONLY Application Accepted by Date Area 04 ! Pit or Grout Inspection by �-7 jDaatte Final Ins apction by(j' I Date Additional Comments: / �7 1 4�_3y 6 ❑ Stk 466-6781 ❑ Lodi 369-3621 16 Manteca 823-7104 ❑ Tracy 835-6385 ,,,.,.,,,,Applicant=Return all copies-to:-Environmental-Health...P.ermit4Services 1601-h.-Hazelton-Ave_,--.O,-Box•2009, Stk., CA 95201 FEE INFO AMOUNT DUE-7- -;;PAMRUNT;REMITTED CASH CK 9 RECEIVED 8 DATE PERMIT'NO. +.EH 13-24 IREY,I A sl E EH 1426- - t