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F APPLICATION FOR PERMIT D SAN JOAQUIN LOCAL HEALTH DISTRICT ,� �1Z 1601 E. HAZE T ON AVE., STOCKTON, CA oroTelephone (209) 466-6761 0A1 A- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EN'4olA jSER�� (Complete in Triplicate) FERo 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. .. ll Job Address 7-5e) City _��N�r/ULot Size PM i Owner's Name /�L/�i � LL1E 1 � Address _ + 'z!rF Phone 0 07 ✓ +� Contractor IDf > Address-,2 ka,ft License No.^T � —I Phone t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP WSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ ❑ Industrial ❑ Open Bottom CJ Manteca Dia. of Well Excavation Dia. of Well Casing ]Domestic/Private Ci Gravel Pack 0 Tracy Type of Casing Specifications ['1 Public n Other ❑ Deita Depth of Grout Seal Type of Grout _ I I Irrigation __ Approx. Depth f 1'Eastern`. SWlaco Seal Installed by _ \ Repair Work Done LJ Type of Pump — L-&1 _ _ ii P. �Z— State Work Dona �7�]/ff Wel! Destruction EJ Well Diameter �~ -- Sealing Material.(top 50'1 t id T �7'zz 3f1�+ � I - Depth Filler Ma11 terial (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I 11L AIR1ADOMON I I DESTRUCTION t I INo septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence _ Commercial Other 4 Number of living units: Number of bedrooms _. 4 Character of soil to a depth of 3 feet: Water table depth Ii SEPTIC TANK O Type/Mfg Capacity_ No. Compartments ` PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line z LEACHING LINE ❑ No. & Length of lines _ Total length/size t FILTER BED 0 Distance to nearest: Well -__ Foundation Property Line SEEPAGE PITS I I Depth Size Number { SUMPS Ll Distance to nearest: Weil_ Foundation Property Line f DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joagbin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i 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 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 om ensa- tion laws of California." ' The applicant or I require c ' ns. Complete dowing on rev se side. C { Signed X v /�, FTitl0: -gip Date: t �' ! J k FO P f?MENT USE ONLY n �J Application Accepted by Date Area t--� i. '. Pit or Grout Inspection by D,a,j Fina! Inspection by ` (7 Date i Additional Comments: ❑ Stk -466-6781- "" ❑ Lodi-._3&9=3621 0 Mdriteca 823.7704_._._"'Cr Tracy 835-6385"'-- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24(REV.rixslS .r�31 EH 14-26 tvvv�