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l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT R 1601 E. HAZEL—ION 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. I k ' Job Address 3� ` r;y"4z1 "' E1� 7 _ city f� FL�ot Size �_ =� PM t 4 Owners Name 1 i2D I F_ f J 1 1 11Ee_ Address - _ Phone a r Contractor g4g IZ,? . 44r.R4d> Address Z9,C 9- y1LLZAA-1 +IIy License No. -� 7� ? Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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. ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by l Repair Work Done ❑ Type of Pump H.P. State Work Done ? w ' Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 oQ TYPE OF SEPTIC WORK: NEW INSTAL TION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other r Number of living units: —]— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth I t5A IJ 11' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments (b' PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well " Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED [5Distance to.nearerst: Well Foundation Property Line 1 � i SEEPAGE PITS ❑ Depth Size Number 'SUMPS _ _ 171 to nearest: Well Foundation Property Line kDISPOSAL P.ONDS•-'"'�O 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. k Home owner or licensed agent's signature certifles 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,1 shall employ persons subject to workman's compensa- tion laws of California." ., The applicant must call for all required inspections. Complete drawing on reverse side. I: Signed ; � Title:�-�"� a.. ( Dater s- FOR DEPARTMENT USE ONLY A Application Accepted by c.� Date Area � �f Pit or Grout Inspection by Date ._ Final Inspection by Date d itional Comments: tk 466 6781 ❑ Lodi 362 .- - -O Manteca 823-7104 O Tracy -83rr6385 _^ Yrr+ s� C vl/�.�`� A plicant- Return all copies to: Environmental Health Permit/ rvices 1601 . Hazelton Ave., P.O. Box 2009, Stk., CA 95201 '__,,__U�,j/"]f� t- OW 4x, FEE AMOUNT DUE AMOUNT REMITTED CK RECEIV9 BY DATE PERMIT'NO. INFO CASH + EH 13-24(REV.1/e al EH 14-28