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APPLICATION FOR PERMIT 1" 0 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address � � � Ciof Size _391 Owner's Name OID /fL Address _27Q3 eS, ZtA2_ /1PhoneContrac gr'amk LicenseNo. 27T 2i PhonSeQ i A / TYPE 0FTL/�I. PUMQ: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ � P M I ALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO.T�I MQ S7,i"SEP K SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE VELL OTHER WELL PITS/SUMPS •YJ INTENDED USE TYPE OF WELL PROBLEM AREA CONS TION SPECIFICATIONS ! O ❑ Industrial ❑ Open Bottom CI Manteca Dia. of Well avation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack T c of singe Specifications -.).w \ ❑ Public ❑ Other ❑ De to \_ epth of rout Sea ��•,.� a 'Grp rt ❑ Irrigation _Approx. Depth JC3] EasteraQT 11 rface al Installed by Repair Work Done ❑ Type of Pump H.P. �t3'te',M1 e •t •� Well Destruction ❑ Well Diameter 'S88L g a ena to 50' Depth Filler Mate I (Bel i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ DD DESTRUiY 0 o septi i 6- eewertie— G /►1A vailabl9 in 2 t. {�V( Installation will serve: Residence-4 Commercial_ Othcr. br Number of living units: N1umb`e`r of bedro s Character of soil to a depth of 3det�`' �� Water table depth p SEPTIC TANK ❑ Type/M <' Capacity No,tmp�gtmen�� PKG. TREATMENT PLT. ❑ f Method,of D{s 1 Distance to nearest: Well_�� Foundation Property Line}.. 10 LEACHING LINE No. & Length of lines ? _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 followingcerti n the performance of the work for which this permit is issued, I shall not - 'h any person in such manner as to become subject man's compensation o1`alifornia."Contracto/s hiring or sub-contracting signature certifies the following: "I certify that in the pertorm of the work for which this permit is issued all employ persons subject to workman's compensa- tion laws of California." The applicant mus all Ftquir ��vory Complete drawing on reverse m Signed Title: 1 s Date: R DEPARTMENT USE ONL % � \l Application Accepted by Date IA `Area Pit or Grout Inspectio b Date Final Inspection by \ Date l l Additional Comma _ ❑ Stk 4666781 ❑ Lodi 3"1 ❑ Manteca 823-7104 ❑ Tracy 835-8385 '•t Applicant- Retu all copies to: Envi onmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.., CA 95201 '•` —_"' FA FEE AMOUNI611b T•AOONT•REM "-RECEIVED"BY"'"- ""'D�-`�ATE '"• PERMIT•N6. "'"