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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 1.YEAR FROM DATE ISSUED E f, (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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r p Job Address 10915 f NC C� City 57,E Lot Size PM 0}^ r Owner's Name Address Qd �3 �Lk�`C � Phone S "��06 Contractor's Name License No. as S03 Phone I ;TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑' DESTRUCTION ❑ r PUMP INSTALLATION JR SYSTEM REPAIR ❑ OTHER ❑ ,. _. .. F. et DISTANCE TO NEAREST: SEPTIC TANK ----- SEWER LINES DISPOSAL-FLD.� PROP.,,LINE j r i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` ❑ Industrial f ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack f ❑ Tracy Type of Casing Specifications 9 Public ❑ Other A w.� ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx.IDepth ❑ Eastern Surface Seal Installed by ' Repair Work Done' ❑ Type of Pump -Sys H.P. �e J State Work Done &&A mgTl l o7 4m Well Destruction ❑ Well Diameter Sealing Material (top 501 # Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) " I i Installation will serve: Residence J Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i Water table depth o?L) SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. !, Method of Disposal { Distance to nearest: Well Foundation Property Line 0 ._ LEACHING LINE'- ..1 , 0 No. & Length of lines Total length/size FILTER BED ,•❑ Distance to nearest: Well Foundation Property Line I k SEEPAGE PITS ❑ Depth � ' Size Number S SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 i I hereby certify that I have prepared this'applicagon4nd that the work will be"done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin:Locd(Realth District. Home owner or licensed agent's signature certifies the following: '9 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 11 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.{' 1E The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: —9=i0a2L=' Date: ' �~ M FOR DEPARTMENT USE ONLY 4 i Application Accepted by Date '2 7 Area Pit or Grout Inspection by l ! Date Final inspecti by 4 j ditional Comments: Stk 466-&781 ❑ Lodi 369-3621 17 Manteca 823-7104 EI Tracy 835-63$5 %• 'A' plicant ',Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.b. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REM CASH CK 11 ' RECEIVED BY DATE PERMIT"NO. . EH 1324{RE'V 10163) r EK 1428 Zls ¢