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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES VYEAR 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. d 1 Jab Address 7.3 9 //1�.Ip+ AN NC� City 1?4VA/ Lot Size PM Owner's Name STCve Addresses` 9g /leo' ' aN Ii� Phone 'i0 I Q 'License No. Phone S 3-rl•x��j Contractor Tf/l)/Yr �_ S��' Address 6DQ� B1-rJt~ Urz' �}v �. TYPE OF WELL/PUMP: NEW WELL ❑ -.. WELL REPLACEMENT f�a ,�) 'DESTRUCTION [IX PUMP INSTALLATION ❑ `� SYSTEM REPAIR D,,t,,,,�\ 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 e ❑ Industrial ❑ Open Bottom ❑'Manteca Dia. of'Well Excavation I Dia. of Well Casing 4! ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [-I Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _-Approx. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. ~State Work Done_ 1 Well Destruction ❑ Well Diameter Sealing Material (top-50_) N Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial, Other La' Number of living units: Number of bedrooms tL'� Character'of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg,I Capacity No, Compartments PKG. TREATMENT PLT. © i Method of-Disposal r Distance to nearest: Well Foundation Property Line p r _ �� J LEACHING LINE 21 No. & Length of lines " C740D Total.len gth/size !90 t y FILTER BED ❑ Distance to nearest: Well ddb-IF– Foundation �¢ •° Y� Property Line S' SEEPAGE PITS l I Depth Size -'Number.✓ t., SUMPS L] 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 cb my 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 df 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." Contractor's(tiring 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 call for ail required inspections. Complete raving on reverse side. J ' Signed X Title: '~ Date: FOR DEPARTMENT Application Accepted by Date 3 Area Inspection bf Pit or Grout Inspy Date Final Inspection by Date ✓� ill Additional Comments: ❑ Stk 466-6781 ❑ Lodi '369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 Applicant - Return all copies to: E_nvirorimentel Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE {. AMOUNT REMITTED. SH RECEIVED BY DATE PERMIT-NO. INFO ..EH 13-21(REV.+/x 5f Lt Imo/ -LD qC1 S EH t4-26