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�� ( Z, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 wall/pump and the Rules and Regulations of the San Joaquin _ Local Health District. .^s1—�rn �j c-� �_—.' Job Address 1TDV S. EscAsr�.�.xO,,m --.DE,L L OTA PA,City ILot Size /L��• PM Owner's Name Fg)s'rEe'T&4WJZEy {FW�tAddress '000 LAIII, T J 1• Phone s , Contractor O.t_J 61 left Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SVSTE REPAIR ❑ / OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER INES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUTURE ELL OTHER W&L PITS/SUMPS _ INTENDED USE TYPEOF.WELL 'PROBLEM AREAVDth CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca ll Excavation Dia.of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy sing Specifications 1"1 Public ❑ Other ❑ Delta rout Seat Type of Grout I I Irrigation _Approx. Depth I 1 Eastern al Installed by _ Repair Work Done ❑ Type of Pump .P. State Work Done_ Well Destruction ❑ Well Diameter Searing Material(top 50') Depth Filler Material IBelow,501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I l DESTRUCTION I I (No septic system permitted If public sewer is available within 200 feet.) Installation will serve: Residence &"* Commercial_ Other ` Number of living units: Number of bedrooms 3 _ Character of soil to a depth of 3 feet: P Water table depth SEPTIC TANK ❑ Type/Mfg Capacity JZm No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal (- Distance to nearest: Well Foundation Property Line LEACHING LINE No.8 Length of lines 22 A ICotal length/size ` FILTER BED ❑ Distance to nearest: Wall Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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, an rules and regulations of the San Joaquin Local Health District. ` Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this pernot is issued, I shall not r 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 shelf employ persons subject to workman's compensa tion laws of California." The applicant must call for all re uired inspections. Complete drawing on/reverser side. M r Signed X(_��(/ � Title: _j�.O s—+...-w. Date: 00 (/ ,.��\> FO\R\DEPARTMENT USE ONLY Application Accepted by L/k �•`.L�'++- NvnQiwnn Date ��UQQl Area _yp Pit or Grout Inspection by Date Final Inspection byF _EE'➢� Date Additional Comments: qp-xa' C1zsCGi S' C✓ O �' 3�� ` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ lAameca 823-7104 ❑ Tracy IL35-6386 r� 3 �f g(, Lf Z) Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, ark., CA 95201 ` . FEE NFO OUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. • EH t}N(REV.11 x st (9-0 (�_� �7