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Il APPLICATION FOR PERMIT ; . �. " SAN JOAQUIN LOCAL HEALTH DISTRICT 1.601 E. HAZELTON AVE.,�STOCKTON, CA i; Telephone (209) 466-678146 lr� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate} r- . 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 SW ! (/Jb�f City. Lot Size pM ;r r _ n Owner's Name 7i1I�QJ_ 4,gh.Address 77 Phone // /` Contractor , �� '�1 Address cense No. Vi' ' Phone l TYPE OF WELL/PUMP: ,r NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- DISPOSAL FLD. PROP. LINE FOUNDATION S1 AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑-Manteca Dia. of Well Excavation ;th f Well Casing ❑ DomesticlPrivate ❑ Grave( Pack EI Tracy Type of Casing fications ❑ Public ❑ Other �❑ Delta 4 Depth of Grout Seal 1 of Grout❑ Irrigation �pprox. Depth ❑ Eastern Surface Seal Installed byRepair Work Done ❑ Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter; — Sealing Material {tap 50;)Depth E Filler Material (Below 50'1TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ iNo:septic mitted if public sewer is available wiet.) Installation will serve: Residence Commercial Other 'Number of living unitsNumber of bedrooms -Character of soil to at depth of 3 feet: y.y. Wate SEPTIC TANK ❑ Type/Mfg Capacity F i No. Compartments PKG. TREATMENT PLT. 1-11 ; M f..f # jli 1 E Method of Disposal t Distance to nearest: Well l oundationProperty Line t � LEACHING LINE ❑ No. & Length�of lines-2 aTotal length/size FILTER BED ❑ Distance to nearest ` Weil s 1� .. Foundation Ptoperty Line SEEPAGE PITS ❑ Depth Size z Number SUMPS ❑ Distance to nearest: Well — Foundation "Property Line DISPOSAL PONDS ❑ I. f 1 x 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,Joa uin 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." j� f The applican st call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: T� FOR DEPARTMENT USE ONLY l 4 Application Accepted by Date 8� Area 0 + _ _ - Pit or Grout inspectio Date Final Inspection by Date Additional Comments: GG 7 1 ! 4e,Yr fly ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy- 83&45365t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O:,Box-2009, Stk., CA 95201FEE ,1 INFO AMOUNT DUES AMOUNT REMITTED CK RECEIVED BY DATE PERMI7'NO. ! p + EH 13-24 iREV.I/n 5} may,, EH 1428