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�. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA r Telephone (209) 466-6781 i. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED = (Complete in Triplicate) Application is hereby made to 4 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 Rules and Regulations of the San Joaquin Local Health District. MM Job Address �xz ' ry City Lot Size c:-D /J--O lip _ Owner's Nam - (' Address —+�- Phone 'c4e-.7x C11 6 Contractor's!Name ,o0W.X1Z1XW 2E 16411r, License No. �'�4/ � 3 Y� Phone TYPE OF WELL/PUMP: I µ*NEW WELL ❑ - WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �"t 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 CONSTRUCTIONSPECIFiCATIONS 6 t ❑ Industrial ❑ Open Bottom ❑•Mbnteca Dia."of-Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑-..Tracy Type of Casing' `r Specifications ❑ Public ❑ Other C1 Delta Depth of Grout Seal Type of Grout l El Irrigation �pprox. Depth „❑ Eastern �' Surface Seai,lnstalled bye, ti`) Repair Work Done ❑ Typei!of Pump , Wil_,P_.J State Work Done t Well Destruction ❑ Well Diameter Sealing Material Itop 50') De tli Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Er DESTRUCTION ❑ (No septic`system permitted if public sewer is '1 available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number-af_bedrooms ,, f Character of soil to a depth ofh 3 feet: _61 • 19Y "" � ti Water table depth SEPTIC TANK ❑ Type/Mfg i. Capacity No. Compartments PKG. TREATMENT PLT. ❑ Wiz.s"�' 4 I� Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE �N'� & Length of lines OLI �' '.� Total length/size G FILTER BED ❑ Distance to nearest:. Well �Foun a�tipn Property Line f SEEPAGE PITS Depth Size Mfr •-�-' Number SUMPS ❑ Distance to nearest: Well ZVEA. Foundation A-6 f Property Line LJ { F DISPOSAL PONDS ❑ IN q 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. s Home owner or licensed agents signature certifies the following: "I certify that in the performance of`the work for which this permit is issued I shall n I, Pe p a of employ any person in such manner as to become subject to workman'i;:compensation laws of California."Contractors 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.' I�. The applicant call for all required ins trio omplete drawing on reverse � Signed Tide' " Date: a FOR DEPARTMENT USE ONLY 1 Application Accepted by Date �2 Area CO Pit or Grout Inspection by !� Da Final Inspection by k ate 73-0 Additional Comments: II I g ❑ Stk 466-6781 ❑ Lodi 1369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to:3!Environmental-Health-Permit/Services-1601-E-Hazelton Ave.,P:O.-Box-2009;Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CC4KSH RECEIVED BY DATE PERMIT NO. +EH 13-24{REV"10!83) T-D �� 1)-44 IN—-15,7F _.,SEH 14-28 l'