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APPLICATION FOR PERMIT / SAN JOAQUIN LOCAL HEALTH DISTRICT SCANNED—1 0 1601 E. HAZELTON AVE., STOCKTON, CA Jl,�'+NNED 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. + ��,.. fT z1 Job Address _nn(.on� ,� �_�1(f�_AJClE City /7z9'�r��'t Lot Size1,6 PM Owner's Name I L u!V P FyO-"1Adddress r��i�ri una D LSA le.b Phorre Contractor Ad 'F1LL6712 Address ' [0t ��7 Ard - 4 . License No.e9Al2 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: NK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom O Manteca Dia. oftion _ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal of Grout I,� ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed.by �'l Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION X DESTRUCTION ❑ (No septic system permitted it public sewer is available within 2Do feet.) Installation will serve: Residence_,e Commercial_ Other Number of living units: -/ — Number of bedrooms Character of soil to a depth of 3 feet: :r 4l it/ <, /_X // Water table depth SEPTIC TANK ❑ Type/Mfg packs No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line �� LEACHING LINE 74 No. & Length of lines 0 '--1- Total length/size ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 II re irad in ctions. Complete drawing on reverse side. Signed X_ Title: Date: _ FOR DEPARTMENT USE ONLY Application Accepted by c dZLc Date /c:a15Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 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 CASH RECEIVED BY DATE PERMIT NO. - + EH 13-241REV.I/e 5) t� v,L C� l2-/?-3787_ 1/339 EH 14M