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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _j 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Ar!r Lot Size PM Owner's NameVf�� j9 U0LSES[ Address _ k 5;14 �'R: Phone 1K 013 Contractor's Name C Sr 1A.>G License No. Phone 3a/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ N DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �- L] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing _ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depti-of Grout Seal Type of Grout ^. ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by (V 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 IR REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.} Installation will serve: Residence_ Commercial_ Other F Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK .A' Type/Mfg COW W Capacity I<CS G No. Compartments PKG. TREP�TMENT PLT. ❑ Method of Disposal Distance to nearest: Well A42-0 4- Foundation /0 Property Line LEACHING LINE %• No. & Length of lines j2 Total length/size 1'7 4 FILTER BED ❑ Distance to nearest: Well APD j Foundation LP it Property Line SEEPAGE PITS DepthSize 33�?C 2S Number SUMPS ❑ Distance to nearest: Well��_.C." Foundation /o f— Property Line 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 District. 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 applica ust call or required inspect, s plate drawing on reverse side. L ' Signed Title: 4 J?�—SS /'z )C C Date: FOR DEPARTMENT USE ONLY Q Application Accepted by Date — a Area d 1Pit 95- Grout Inspection by Date inal Inspection by Date Additional Comments: 04, ❑ Stk 466-6781 KLodi 368-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all 21pW to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2000, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH1324(REV.10!83) !303 ;0 EH 4426 a_ �_