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n APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE„ STOCKTON, CA Telephone (209) 466-6781 (a FyPERMIT EXPIRES TYEAR FROM DATE ISSUE (Complete irl'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 n % :�l V1 .'7 1L:_. � ��O tt 3 Job Address — �.��—��- r City� C�1 Lot Size � r�`-�►�-G`� PM Owner's Name t -S Address .T- C eL Phoneme. ` 4 Contractor IfGt l f. "� ati Address i t-VL _2L License Noc7?_C)L4__A_�-PhoneEt'161_a7ll TYPE OF WELL/PUMP: NEW WELL 15iL WELL REPLACEMENT , DESTRUCTION ❑ PUMP INSTALSYSTEM REPA16 0 OTHER P _ DISTANCE TO NEAREST: SEPTIC TANK 1 j=? - z SEWER LINES DISPOSAL FLD.�� PROP. LINE —� FOUNDATION AGRICULTURE WELL OTHER WELT.12=- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA - CONSTRUCTION SPECIFICATIONS (� ❑ Industrial Open Bottom © Manteca Dia. of Well Excavation cZ Dia. of Well Casing 5 V, 'Domestic/Private C] Gravel Pack ❑ Tracy Type of Casing - CG Z Specifications (`l Public Cl Other C 1 Delia Depth of Grout Seal Typp.�f/Grout C�tule_vl i I I Irrigation J �ANpptox. Depth t I Eastern Surface Seal Installed by l z rt ft I Repair Work Dane 11Type'6f-Pump W + , H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 "117 PAIR/ADDITION l I DFSTRUCTION I 1"(No septic system permitted if public sewer is available within 200 feet.) VVV Installation will serve: Residence_ Commercial_ Other Q Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments } PKG. TREATMENT PLT. D Method of Disposal Distance to neatest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size [ FILTER BED ❑ Distance to nearest:, Wel! Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well _ Foundation 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 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 t call for all Ye uired inspections.-Complete drawing on reverse side. _ Signed /�(�t�� '+ � tT�.. _ Title: '-,e-C- Date: F R DEPARTMENT USE ONLY Application Accepted by Date7 et �'±� Area " s , Pit or Grout Inspection by 1K61 lad( D:::� - Final Inspection by Date ¢¢,, Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-301 ❑ Manteca 823-7104. ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE �PEJRMff NO. .+.EH 13-24(REV.I/y sl L2rj Q C- �.0'� , �_ �-'fes / r� 7`. t EH 14-2e J /`.,' r. CEJ cc']� 0