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" APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. p� Job Address _ l a 6qq (_ jAI� oAU City ( l� � Lot Size fly •'!/ PM Owner's Name 611 FFC-D YftT0 KE Address 18541 6 !Mf I fn ICS Phone Contractor 's, Address License No. Phone TYPE OF WEl_L/PUMP-7t NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 L] Public I_J Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation ---Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ N11 Well Destruction C] Well Diameter Sealing Material (top 50') n Depth Filler Material (Below 50') TYPE OF SEPTIC WORK; NEW INSTALLATION 04 REPAIR/ADDITION i I DESTRUCTION i I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_X_ Commercial_ Other Number of living units: __L_ Number of bedr'gams Z Character of soil to a depth of 3 feet: _pI� t fi, Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 1-1 6 GAI No. Compartments PKG. TREATMENT PLT, C] Method of Disposal Distance to nearest: Well 1- Foundation too Property Line X10 LEACHING LINE ❑ No. & Length of lines .Z Total length/size �a FILTER BED ❑ Distance to nearest: Well I25 r Foundation 1 � Property Line (030 SEEPAGE PITS l I Depth Size Number SUMPS Cl 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 with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health DiMrict. 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 no 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 c IIV all requir pections. Complete drawing on reverse side. (� Signed X Title: -- � Date: r ~ z 3 F01 EPARTMENT USE ONLY Q Application Accepted by Date `� `� Area Pit or Grout Inspection by Date Final Inspection b I Date 25—cfflv Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-&185 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO A�M�O�eU'�NT DUE AMOUNT REMITTED C SH RECEIVED BY DATE �y JQPERMIT'NO. • EH 132 (REV.t/H 51 /V' O ` O..f EH 14-26 J