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APPLICATION FOR PERMIT V SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 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. Job Address � -n y It 7'j F-0 V--'O Cit �- Lot Size PM Owner's Name 'l� zz Lir 'R r�KJ FzC.�I Address LSI '2 v�6 Phone n Contractor�J K L-�1 K Ft LLI Address 73 60 LL--1 e C JN4 License Nq.J i15.LiYL Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL_FLO. PROP. LINE \i - - 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 0 Tracy Type of Casing Specifications FI Public ❑ Other ❑z Delta Depth of Grout Seal Type of Grout_. h I I Irrigation _Approx. Depth I I 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 I I At PAIR/ADDITION 41.-DESTRUCTION I I (No septic system permitted if public sewer is _ available within 200 feet.) Installation will serve: Residence✓mmercialOther - - Number of living units: -t/— Number of bedrooms Character of soil to a depth of 3 feet: 16�'9 in lk�� Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 3- f O. & Length of lines Tgtal length/size IJ FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS Lk- h Size 3 Number r SUMPS Ll Distance [o nearest. Well Fcundation _ Property Lina DISPOSAL PONOS ❑ 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 cenifies 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 sub-contracting signature certifl a following: I certify at in the performance of the work for which this permit is issued. I shall employ persons subject to workman's compensa tion laws o mia." The applicant ust c I all quire in p -ion Com d awing on re soseysi( Sign e: ✓� - � Date: e FOR DEPARTMENT USE ONLY �� Application Accepted by _ Date��.]� r� Area g� Pit or Grout Inspection C.... Final Inspection by ��`7cY^��'-a Lt 2 L�X Data `s Additional Comments: - .r ^�`� �-d O" r'Z ❑ Slit 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 ❑ Tracy 635.6385 ;� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, tk., CA 95201 l INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE (c,PERMIT NO. � 00- EH 0 EH 1, r%