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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.—_I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i 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 5 r 0 r ' �� City 1 0 r { Lot Size I°2 , PM ��. ars fo5 QMH 5 99-64 �/� Owner's Name Y �e COCO-0-5O j Q Y1 Address - phone Phone Contractor 0C.Uylf=42Address Sa M - License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP. 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout n ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 1`fl✓� Repair Work Done' ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 (n TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is V available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms / Character of soil.to a depth of 3 feet: a-n Water table depth SEPTIC TANK' Type/Mfg Capacity 1700 No. Compartments c2 PKG. TREATMENT PLT. ❑ f Method of Disposal Distance to nearest: WellFoundation _ Property Line�� I LEACHING LINE ❑ No. & Length of lines s2 Q Total length/size FILTER BED �PDistance to nearest: Well >/00. Foundation----1GW Property Line SEEPAGE PITS ❑ Depth Size Number .SUMPS ❑ Distance to nearest: Well Foundation A 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 fallowing: "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."Contractods 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 applican u t cal or all required inspections. Complete drawing on reverse side. Signed _ _ Title: Date: n�'r 7 ne FOR DEPARTMENT USE ONLY Application Accepted byL /\T.t_�t/�--�� Date 9-7 Area Pit or Grout inspection b Date Final Inspection by Date�� E -l'c 54" rv�5c ��er� ctJ In (a Additional Comments: I S G`t r) Or P�� ❑ Stk 466-6761 ❑ Lodi -3621 anteca 823-7104 ❑ Tracy 835-6385 �jl lrje 1't � Applicant- Return all copies to: Environmental H alth Permit/Services 1601 E. Hazekon Ave., P.O.0.b 2008, Stk., CA P5201 1 e 5,2 11;Le FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. 0L__+ EH 14-24IREV.1/a 5f 1 -7o00 EH 1 "7O - ZS9 426