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�. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) 1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TMs 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 g2a k/V,4 gni -- City Lot Size G PM I t Owner's Name �'�i7 442��C'. 6c14SI Address _ Phone r elf.__ _ -.• ... _. . � � Contractor �t �L�G-1( Address /6, � /Y�'%dA License No—%a� ._. Phone TYPE OF WELL/PUMP: NEW WELL U WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U 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 .— El Industrial .El Open Bottom a Manteca Dia. of Wall Excavation ._ __ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ___-__ Specifications 0 71 Public Cl Other 11 Delta Depth of Grout Seal Type of Grow 1 1 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 50') N1 TYPE OF SFPTIC WORK: _NEW INSTALI_ATION.)(_REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation wit] serve: Residence Commercial Other Number of living units _L_ Number of bedrooms _ y i 1 L L Character of soil to a depth o1 3 feet: Water table depth SEPTIC TANK Cl Type/Mfg P..� �. pacity – - No. Compartments PKG. TREATMENT PLT. U �� >�,�T ''7- Method of Disposal Distance to nearest:` Well SQ �T Foundation Property Line LEACHING LINE t5e No. & Length of lines Z42V 2 Total length/size FILTER BED ❑ Distance to nearest: Well.&>r 'Foundation 1� � Property Line SEEPAGE PITS I I Depth Size ' Number SUMPS Cl Distance to nearest: Well ______ Foundation _. Property Line DISPOSAL PONDS Cl 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 D+~strict. Home owner w 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, I shall employ persons subject to workman's compensa- tion laws of California. The applicant must call for al! uire inspections. Complete drawing on reverse side. Signed X_ z Title: Date: '&/-,.2/-�'p FOR DEPARTMENT USE ONLY Application Accepted byDate Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63.85 Applicant_ Return all copies to: Environmental Health Permit/Services 1601 E. Hazefton Ave., P.O. Box 2009, Sik., CA 95201 FEECK 4 INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. a� 3! r t.EH 1-24 IREV. EH 1426 I��