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APPLICATION FOR PERMIT SAN JOAQUIN`LOCAL,HEALTH DISTRICT 1.601 E. HAZELT ON AVE., STOCKTON, CA f r Telephone (249) 466-6781 PERMIT EXPIRES 1 YIEAR FROM DATE ISSUED a� (Complete in Triplicate) �¢Q-�60-1, 2 Application is-hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereir°47icrfibed. This application is made in r ompliance 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. Job Address '5491 F. St. City_.�Ax,T_AL Lot Size 115�X 'ZOO, PM Owner's Name Address �J'19 V7. Phone Contractor ETS ef4ugsGf�� mdress?.a, 5a 'L2$'L CA License No. Phone 01 ; TYPE OF,WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ l r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER IN i�1CNtT6RIAia�u3'2t�S �'! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom 1K Manteca Dia- of Well Excavation rI Dia. of Well Casing rr ❑ Dome''stic/Private ❑ Gravel Pack ❑ Tracy Type of Casing pJ G Specifications i tl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout SeAz 1Cic I I I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by o V1PFlPaC Repair Work Done ❑ Type of Pump H.P. State Work Done_ 1 Well Destruction ❑ Well Diameter Sealing Material Itop 501 1k Depth Filler Material !Below 501 TYPE OF, SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is i available within 200 feet.) r. Installation will serve: Residence_ Commercial_ 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 LEACHING LINE ❑ No. & Length of linestUtA il�J'�t` FILTER ED ❑. Distance to nearest: - Well _ nhition f•,� t fip� Line f n SEEPAA PITS I I Depth Size SUMPS i 0 Distance to nearest: Well � Property Line 1 DISPOSAL PONDS o �vrA� E41 T4, I hereby"lcertify that I have prepared this application and that the work will lie on � th San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dl�trict. 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,l shall employ persons subject to workman's compensa- tion laws of California." The app tc ust call for all quired inspections. Complete drawing on reverse side. —y Signed X, Title: Date: /"'2-7�TR I FOR DEPARTMENT USE ONLY Applicata n Accepted by Date�- Area .-.. f Pit or Glut Inspection by Dater �__... Final Inspection by_r Datdxp t i Additional Comments: '- ❑ Stk 1466-6781 ❑ 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 AMOUNT DUE AMOUNT REMITTED C RECEIVED 9Y DATE PERMIT'NO. INFO I + EH 14-I6IREV-7/n51 �� _