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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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /v7) �% 1/1 (' u^ f /y) /'� �,�,, Job Address 2333, V / ` / "C ~� ' \` City F✓"'�ot Size PM LP UI 0 z I hereby certify that 1 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 subcontracting 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 ¢jq�ust call for I re/yuired ins p actioann¢ Complete drawingon reverse side. �,/ �� (, y/ Signed X_�,l r ,h7 (M'l_.yY Title�% 1Lt- '^'r JUti� Date: �2o e FO DEPARTMENT USE ONL Application Accepted by 4 Date 7 — s -Area Pi r Grout Inspection by��.ar ate �Final Inspection by Date Date Additional Comments: ' O Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-M r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ♦ ER 1321 IREV. 10M EH 1426 FEE INFO Owner's Name / Y/T7" I � — 'Kdrass 2 33 S� N 'Ki©`�� Phone CASH RECEIVED BY/DATE PERMIT NO. ` Contractor's Name icense No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FUD. 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 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Cl (No septic system permitteio if public sewer is available within 2DO feet.) Installation will serve: Residence _ Commercial _ Other ` Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK Type/Mfg CapacityAo. Compartments !1� PKG. TREATMENT PLT. 11F � Method of Disposal Distance to nearest: Well LU Foundation Property Line .1,100-24 LEACHING LINE 8 No. & Length of lines - To al length/size FILTER BED B Distahce to nearest: Well (JV7� Foundation' Property Line SEEPAGE PITS -Eff' Depth �� Size�� Number SUMPS ❑ Distance to nearest: Well � Foundation r Property Line DISPOSAL PONDS ❑ LP UI 0 z I hereby certify that 1 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 subcontracting 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 ¢jq�ust call for I re/yuired ins p actioann¢ Complete drawingon reverse side. �,/ �� (, y/ Signed X_�,l r ,h7 (M'l_.yY Title�% 1Lt- '^'r JUti� Date: �2o e FO DEPARTMENT USE ONL Application Accepted by 4 Date 7 — s -Area Pi r Grout Inspection by��.ar ate �Final Inspection by Date Date Additional Comments: ' O Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-M r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ♦ ER 1321 IREV. 10M EH 1426 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY/DATE PERMIT NO. ` I