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APPLICATION FOR PERMIT ' + SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 112091 466-6781 . t PERMIT EXPIRES 1 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. t Job Address 13V 72 4e/ '/4Vf CA-VC 1 .4 City .�CT,k Lot Size ZLT- )C ?G' O PM Owner's Name 4C11W A�,E"if//.!� M, 4F .S�'�Address _' �'!� Al /"/1 Phone i V 3 Contractor's Name 2:J��i4�'' W LicenseNa. 7 '= _._ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ r '•SYSTEM,REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FGD. PROP. LINE FOUNDATION -AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL• PROBLEM AREA SPECIFICATIONS h ❑ Industrial ❑ Open Bottom ; r ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack. _❑ Tracy Type of Casing Specifications El Public ❑ Other f El Depth of Grout Seal Type of Groutry ❑ Irrigation ---4pprox?Depth ❑.Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. r State Work Done' Well Destruction ❑ Well Diameter 's Sealing Material (top 501 ' i Depth " Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION 0-"REPAIR/ADDITION DESTRUCTION ❑ INo septic system permitted if public sewer is v available within 200 feet.) �- r Installation will serve: Residence-- Commercial Otheraw—&— f lle yw I Number of living units: ..,-. Number of bedrooms e Character oYsoil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments i l PKG'TREATMENT PLT. ❑ -�.--- _,,,,_,„-Method of Disposal 1 Distance to nearest: Well� :- Foundation_,..._ Property--Line I LEACHING LINE ❑ No. & Length of lines ______.T.atal-length/.size j FILTER BED Distance 3to nee rest: Well Foundation Property Line SEEPAGE PITS ❑ Depth �kt'd _Size �e Number f __ F SUMPS Distance to nearest:,-----•Well+- Foundation Z0'r Property Line 12 DISPOSAL PONDS ❑ 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; "!certify that in the performance of the work for which this permit is issued, I shall not i 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 perforinance•of-the•work,for-which-this•permit-is issued;-I shall.employ-persons subject to workman's compensa- tion laws of California." The-applicant call for all requi d.inspections.9omplete drawing on reverse side. ` Sign{ed X R. /a Title; Date: -2 i # FOR DEPARTMENT USE ONLY { ltt ` t Application Accepted by Date is ^-Z Area Pit or,.Grout Inspection by ; Date t Final Inspection by Data, - -�y F ,Additional Comments: OiAStk 466-6781 Lodi '1 } I 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental-Health-Permit/Services 1601-f-Hazelton Ave:,P:O-Box2009,Stk.=CA 95MI .l FEE AMOUNT DUE f AMOUNT.REMITT. CK# , RECEIVED'SY DATE k PERMIT' INFO CASH '°, + EH 13-24(REV.10163) �_ f EH 14-28 - -- ��/i�Te