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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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. n ,t C Job Address — '2,,`�114 /y�-U��r'4 City's Lot Size PM Owner's Nam e�1 ho" isN Address Phone �j t, Contractor Address License No�Phone Zha_s 4 ` 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 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 ('1 Public El Other FI,Delta Depth of Grout Seal Type of Grout_ _ I I Irrigation _.Approx. Depth I 1 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 f8elow,50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ESTRUCTION I I (No septic system permitted if public sewer is ' available within 200 feel.) O Installation will serve: Residence ` _ Commercial t2Other Number of living units: Number of br � �dr,00m�s �J Character of soil to a depth of 3 feet: _H1)IV)7AT--) Water table depth ` SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments mac" PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Lt1'�No.& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation it Property Line SEEPAGE PITS I%L—Depthy_Size T�utt)ber SUMPS Ll Distance to nearest: Well 10 r Foundation_—E7L.C_7 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 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 a Califor ia." The applican rm II for all r uir insc s.�owing Siswing eed-. Date: 1 y ///J/��FOR RTMENT USE ONLY Application Accepted by / Date Area /� y/� I l' r• Pit or Grout Inspection by Date Final Inspection by � as 1T74L� Date z Additional Comments: 9-,j- ey P ifOK ji c ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑'Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 16301 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT�DUEE AMOUNT REMITTED CK It CASH RECEIVED BY DATE PERMIT'NO. / . EM 13.24(RCat FV.i i x v 0,49-0 �L�•�-7 ` EH u.ze G 'CSO s �!