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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 TYEAR FROM DATE ISSUED O1k, 'redi,C (Complete in Triplicate) Application is hereby made to tffe 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. \ /�/h, Job Address �� w ILLI' �f'V ssop_) �`� City + t`-"'�C� Lot Size PM Owner's Name l!`-��S ti e�f I AL` Address -703 F (,,Q 3 U_A AM S 100 M Phone Z017_,Z31—clici 6LRContractorowowlse+a Address License No. e b TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ -BOTHER'D 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 i ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well.Excavation ilia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications * Public f 1 Other I 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 pone 1 Well Destruction ❑ Well Diameter Sealing Material (top 50') y Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION ESTRUCTION l I (No septic system permitted if public sewer is 1!" available within 200 feet.) i thstallation will serve: Residence_ Commercia"Lo-11— ;Other '['} Number of living units: Number of bedrooms , Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r � I LEACHING LINE ❑ No. & Length of lines Total iengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE ITS I I Depth Size Number 6WE-Ir 1 SUMPS ( -Distance to nearest: Well Foundation Property Line T DISPOSAL'PONDS ❑ 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. 1 r 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The p Ic mu call for all required i pections. Complete drawing oojn reverse side. ry Signed t 't'' Title:�%' AC QyU�� _ Date: �� FORD TMENT USE ONLY Application Accepted by __. . Dat Area A-3 Pit or Grout Inspection by Date Final Inspection by flat . Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ..a Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O,9ax 2009, Silk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT-NO. - +"EH1j3-24IREV. / 51 r cm EH 14-26 1 l I i