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C 4' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED (Corrlplete'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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District Job Address �" City fir�� Lot Size Owner's Name `w >Erl�ul�'�Sf Address' '70(l IA.) - Phone 2-"' Contractor CA Address ISu jyiYbcf sF�lle license Now (4.M 6 Phone 8216S8 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 17 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL OBLEM AREA CONSTRUCTION SPECIFICATIO PRNS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public ❑ Other ,. F1 Delta Depth of Grout Seal Type of Grout -- I I Irrigation __.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. F State Work Dane_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') - _- TYPE OF SEPTIC WORK: NEW INSTALLATION Ivr REPAIRIADDITION I 1 DESTRUCTION t I (No septic system permitted if public sewer is W t / m - -- . _. — .- -- -.— - �- -—available within 200 feet.) O Installation will serve: Residence '✓ Comercial— Other— Number ofliving units: I Number.of bedrooms Character of soil to a depth of 3 feet: -SQN051 _ Water table depth SEPTIC TANK ❑ Type/Mfg c L Capacity Ont? No. Compartments PKG. TREATMENT PLT. ❑ P Method of Disposal Distance to nearest:' Welf 0 --- foundation- Property Line J b 1 r LEACHING LINE C✓ No. & Length of lines. b "OS Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size _ Number SUMPS LT' Distance to nearest: well A34) r Foundation 4?A r Property Line DISPOSAL PONDS ❑ I 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 pert rmance of the work for which this permit is issued, f shall employ persons subject to workman's compensa- tion laws of California." The applicant m 11 for all rei�uir6dd.ins/ tions. Complete drawing on reverse side. d Signed X_ '— �7i_ _ Title: __ CJ �.e11__ _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date v Area Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: .❑ Stk 466-6781 ❑ Lodi 369-3621 LI Manteca 623-7104 - - .-0 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 REC ED BY DATE PERMIT'NO. INFO �/�/� CAS ♦ EH13-24iREV.��nsl ��e(Y� 7¢-� A-01 EH 14-28 //