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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. 509 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ?]$GG E� �/�L�CziY�-Ma-n t)�.r.4. i1Cit'rt�LL ) f3 ,� Lot SizeyC-�J PM Owner's NyFa�me JJO'h �t'`x.1-,40. /-- Address k tici-7( .��v l�� w T $D 4 VLA Phone locl-I I A Contractz_ul /6 S.c-+a+.FC c Address Pa (fax -10 OL�i^-` License No.3a1'aa'6 Phone 36%--51 OS t. 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 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout O I I Irrigation _Approx, Depth I I Eastern Surface Seat Installed by - C, Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence_ Commercial_ Other Number of living units: Number o bedrooms Character of soil to a depth of 3 feet: Water table depth 1040 SEPTIC TANK Olr�Type/Mfg emt Capacity 00 No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal 1 Distance to nearest: Well 0 Y- Foundation 'lio Property Line r. LEACHING LINE r. No. & Length of lines Total length/size 1�0 19 r FILTER BED ❑ Distance to nearest: - Well J70••+' Foundation IA Property Line_a- r. SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, 1 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 10 workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on re` ` reverse side. Signed L Title: V , Date: �f -0`'1 5-f 7 r FOR DEPARTMENT USE ONLY S i Application Accepted by �,-.�. �� "�"� DateArea Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: sy� , ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7100 ❑ Tracy 635-6365 TAL Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK It FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. I f C3,4- INFO [�7 . EN I}21IflEV.rix Si ,� �) ��0 / T73 6 t'