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APPLICATION FOR PERMIT • .tz Y SAN JOAQUIN LOCAL HEALTH DISTRICT " r 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 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 I Local Health District. ` 14 Job Address 4�� :Z 4) t,11 i..j� 1C City _ Lot Size /fo 19/'iz5 PM Owne s Name __nJ1IrJK Address T�+f+ _ 171 i11e0t _ ( Phone G'1 Contractor Address I 41MI 5 1,n nse No.aQ&0 1 I Phone 3irog' 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 y OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i ❑ Public 171 Other Cl Delta Depth of Grout Seal Type of Grout-- I rout _.I i Irrigation __ _Approx. Depth f I Eastern Surface Seal Installed by _ 1� Repair Work Done ❑ Type of Pump H.P. State Work Done E Well Destruction ❑ Well Diameter Sealing Material Itop 501 i Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION KREPAIR/ADDITION 1,1 DESTRUCTION I 1 INb septic system permitted if public sewer is available within 200 feet.) 4' Installation will serve: Reslidencet% Commercial_ Other Number of living units: T Number of bedrooms Character of soil to a depth of 3 feet: Water table depth or ~ ' SEPTIC TANK ❑ Type/Mfg Capacity AWIMP �No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal J# r � Distance to nearest: Wellt�d Foundation 10 Property Line LEACHING LINE _ Ct"INo- & Length of lines r _ Total length/size FILTER SED ❑ Distance to nearest: Well_ � Foundation_. Property Line_4�B r SEEPAGE PITS 14- Depth �S , Size zoo. ��/I ��`_ Number __ SUMPS Ll Distance to nearest: Well�Qi� Foundation �.S` 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: "l 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." The applicant m all all required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date r d� /�� I� :Area /Pyt=or Grout Inspection by. ' Date — Final inspection by ate (/ r A ditional Comments: Stk 466-6781 . El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 pplicant - Return all'copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 r CK FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY . DATE PERMIT'NO. + EH1 -21fR£V.tiK51 EH 1426 �/ ,