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E� I` APPLICATION FOR PERMIT n .,AN JOAQUIN LOCAL HEALTH DISTRIGt 1601 E. HAZEL T ON 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 "_ City _51-AW Lot Size PM Owner's Name ,�(leFr.�F'�,jy�/��f�ydress Phone g ' Contractor At' A&5 AddressZ/67k5i L[1>1, C License No. til Phone TYPE OF WELL/PUMP:' NEIN WELL ❑ ' - WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION )V^0`.Pi4z601&4TSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER.LINES DISPOSAL FLD. PROP. LINA „ FOUNDATION AGRICULTURE WELL a 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 ❑ DomesticlPrivate '❑ Gravel Pack ❑ Tracy Tyll Casing`" Specifications f�Public ❑ Other ❑ Delta Depth of Grout-Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ 4Type of Pump __ H.P. 7Z2 State Work Done p_JJ LL�TUIPE3` i Well Destruction ❑ 'Well Diameter Sealing Material (top 50') Yz > �{ _ Depth Filler Material-(Below 501 0 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑. .REPAIR/ADDITION ❑ DESTRUCTION ❑ANo septic system permitted if public sewer is _.., available within 200 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ' Foundation Prdpeity Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well s Foundation Property Line. - t - A 9 SEEPAGE PITS ❑ Depth :Size Number : SUMPS ❑ Distance to nearest: Welt Foundation Property Line DISPOSAL PONDS 171 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, 1 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 mus all forrll quirecl ' spections. Complete drawing on verse ide. Signed Title: FR DEPARTMENT USE ONLY ;f Application Accepted byLam/ } ~ Date -Area Pit or Grout Inspection b Date Final Inspection by Date A Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83556385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haielton Ave., P.O. Box 2009, Stk., CA 95207" ':FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. + EH18-24 4REV.F/951 14-25 ""'� Eli `� S ,