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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT w, 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) /U7 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 �3 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. i Job Address - ep=�2r�l_/y1 S�S City —At Size_1S PM Owner's Name dunEbI � !�� '� rrk/ 7!� Address Phone Contractor's Name ` License No. 41�3 '. Phone TYPE OF WELL/:PUMP: NEW,WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 'A r> SYSTEM REPAIR ❑ ';OTHER ,[] f DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELLOTHER WELL PITS/SUMPS }r 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 ~l ❑.Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation x ---Approx. Depth ❑ Eastern Surface Seal Installed by I Repair Work Done ❑ 'Type of PumpH.P. State Work Done v; Well Destruction „ ❑ Well Diameter Sealing Material (top 501 y Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION - REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is f available within 200 feet.) Installation will serve: Residence Commercial_� Other T i Number of living units: Number of bedrooms --: Character of soil to a d(ewpth of 3 feet: Water table'depth ld y SEPTIC'TANK1 Type/Mfg S Capacity l No. Compartments 4 PKG.rREATMENT PLT. ❑ �l Method of Dispose v Distance to nearest: Well C>40V Foundation "� Property"Line 4-Nm?,/ ,LEACHING LINE No. & Length of lines ,.Total length/size FILTER BED 0 Distance to nearest: Well Foundation ' Property Line__ /41wp i SEEPAGE PITS ❑ Depth Size Number SUMPS ' ❑ Distance to nearest: Well Foundation~ Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that thework will be done in accordance with San Joaquin couniy'6fdinances, 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' such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the folio : "1 certify that in the performance of the work for which this ermit is issued, i shall employ persons subject to workman's compensa- tion ia%A of C The applica all for al quired ' s ct• s. om to drawing o rev sid Signed Title: r Date: �✓ - .-... - .y.- -•....�s.---- .4 y- -. - _ FOR DEPARTMENT USE ONLY Application Accepted by ' Date V Area V —Pit-or Grout.Inspection-by --. -- - --- - Date Final Inspection-by - - -`Date.��C� i y► Additional Comments: ❑ Stk 466.6781 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385` `Appka;t- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201FEE _ INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT NO. + EH 13-24 IREV,10!831 LAa 1-7 •3 i LiCZ EH 14-28 �`