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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT, 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete 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. //{i -�' Loc) ,✓, Job Address V A-1e"t� ^11"6iUArQ� _ City Lc Lot Size`liJt/4 Y,4.0I PM Owner's Name !�D T'�Ok-1DE� Address��/�UIJsFi ."�'�t�Gl Phorte ` Contractor `+ mf2g Address �• 1:.�`��.1 License No.,ZJ Phone*14 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Y Specifications \ * Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout __ I I Irrigation —.Approx..Depth I 1 Eastern Surface Seal Installed by _ 1 Repair Work Done ❑ Type of Pump H.P. State Work Done v Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/AUDITION DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_X Other s Number of living units: Number f bedrooms Character of soil to a depth of 3 feet: A- Water table depth ��o SEPTIC TANK ;K Type/Mfg Capacity 104>O(SaL .No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal .1 + �P 1 Distance to nearest: Well iM Foundation 1001 Property Line -.._ LEACHING LINE No. & Length of lines G t ria r Total length/size FILTER BED ❑ Distance to nearest: Well71_40 + Foundation t+ Property Line I SEEPAGE PITS I 1 Depth j Size Number X SUMPS LlDistance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ VVV I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinance`s, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. 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." 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 ust call for all requir inspections. Complete drawing on reverse side. �7 Signed X Title: -S'�i �/ T�] Date: E5'202 <3)c) FOR DEPARTMENT USE ONLY `� Application Accepted by Date a �0 _ Area JLl� Pit or Grout Inspection by Date Final Inspection by � I� Date Additional Comments:k4-A ZL��,f� W /� / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 % f Dkbtldv -",4 ,ask 1,4- U r<,r-,r 4 r3 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. B,gx Silk., CA 95201 t 1. FEE AMOUNT DUE .r AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT NO- EH O. ZG SU +.EHt143-28 24{REV.iin51 EH 11 1 Ld �f d� ('�^30—�176`�30DL t] d� 1 �JG?J\