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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 105 G rrude . City S+kth Lot Size _f X PM Owner's Name nurmo -rf _1eL Address - 1� May i-C3 . S San Fran OVL140 FO f_ Contractor H U?Le-d 7f"L(Cf imAddress VIrGI Min No.54a1JCR_2�0-phone P TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 FI Public Cl Other Ll Delta Depth of Grout Seal Type of Grout _ I I Irrigation _Approx. Depth l 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material [Below 501G TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is `h available.within 200 feet.) j Installation will serve: Residence_.V_ Commercial — Other Number of living units: _J.._... Number of bedrooms ` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK X Type/Mfg CL 1r e ni Capacity No. Compartments �f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Ll 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 Di%trict. 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." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applica t call)for all requir d -nspections. Complete drawing on reverse side. / �j Signed 7(�/�X!/I11J Title: .�J Date: Z//&/Tao ,r FOR DEPARTMENT USE ONLY I Application Accepted by Date �` AAreaa Pit or Grout Inspection by Date Final Inspection by r � �'v•' Date G Additional Comments: d 1'75 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2Z*.,Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH REAAACEIVED BY DATE PERMIT'NO. ♦ EH13-24 iRE'V.t/M 5) Q 'f: -� ` ,� O O -i� EH 14-26 �O