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r 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address .,2.'x.2 ,e5. City -T Lot Size /3144 PM Owner's Name ITVh�s✓ Se Z- - a J Address �Zo Phone .3 "C*Zi Contractor Address 60.CAI, ,L 9160 ❑cense No. ll�i-7i Phone V�-V-3'7 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DES UCTION ❑ (No septic "em permitted if public sewer is avail ble thin 200 feet.) Installation will serve: Residence_ Commercial_ Other ` Number of living units: Number of bedrooms CD� Character of soil to a depth of 3 feet: Water table depth C SEPTIC TANK ❑ Type/Mfg - Capacity No. Compartments PKG. TREATMENT PLT. ❑ 0 C Method of Disposal Distance to nearest: Well Foundation Property Line Cb LEACHING LINE No. & Length of lines /��' ` Total length/size '`.lam L FILTER BED ❑ Distance to nearest: Well 0eigitt Foundation SWIP Property Line 4_ SEEPAGE PITS Depth "Z-!r• Size .53 H Number SUMPS ❑ Distance to nearest: Well FoundationProperty Line /00 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 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 orsub-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 m�fforfired inspectio . Complete drawing on varseside.Signed Title: ?. Date: FOR DEPARTMENT USE ONLY Application Accepted by Date e Pit or Grout Inspection by �`' Date Final Inspection by Date �� Additional Comments: 4 'Stk 466-6781 El Lodi 369-3621 E1 Manteca 823-7104 ❑ Tracy 83.5-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK IF— CASH RECEIVED BY. DATE PERMIT'NO. + EH1344PIEV.1/85) EH 1426 ! '-✓ t r ! ( 6 I!0�