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0 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 r^� (Complete in Triplicate) '\\\/��yyJJJllll///' II�IrvJ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work rein crib ThisYaction 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 ///Cre) r" ^'te" 4:T,o+ F—� QG ( City Lot Size PM Owner's Name [�/� /e©��ON Address Phone _-Zy'7,ff' y� Contractorx �f•7 1'Y 6;0,0Z� AddmssA � 0-K3?f! License No.?d_*2(�=Phone 3 1 TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK V0 SEWER LINES DISPOSAL FLD. PROP. LINEr� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATTIIO,rNS�,, ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation 3.- Dia. of Well Casing ))`Domestic/Private Gravel Pack ❑ Tracy Type of Casing�.�c Specifications 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal .3 'v Type of Grout�'k-I�_ I I Irrigation ,,',��Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump -A2 j H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth' Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Q Installan ill serve: Residence_ Commercial_ Other - Number of living un Number of bedrooms Character of soil to a depth o Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well undation Property Line LEACHING LINE ❑ No. & Length of lines ength/size FILTER BED ❑ Distance to nearest: Well Foundation Pro Line SEEPAGE PITS I IDepth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that 1 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."Contractors 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 must call for all re fired inspections. Complete drawing on reverse side. Signed X j,/��i-�: Title:�`�.G, Date: J'/--4'!"'2-,-Ap FOR DEPARTMENT USE ONLY Application Accepted by dt rIL11140t Date a� — Area Pit or Grout Inspection by 4� Date / �O Final Inspection by DateZS'8"� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 11 Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. ♦ EH 13.241REV.1/x51 EH 1t-2e