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If APPLICATION FOR PERMIT I� d SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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. SA4--TZ,5 mss" Ldp, � Job Address _A1, 3 Z/3 �`�?1�13Zo c:!,7- City vV Lot Size PM Owner's Name f�,J, D'o, 'Address,��''Dy'ti' -/;3 !�Z.a Y�.9G�./ Phone Contractor's Name �Z l-�eLGy%!t� License No. �b f� �'z Phone _.g3 -,2 J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D 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 D Gravel Pack D Tracy Type of Casing Specifications ❑ Public ❑ Other I D Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx.,Depth D Eastern Surface Seal Installed by. n Repair Work Done ❑ Type of Pump H.P. State Work Done ' Well Destruction ElWell-Diameter Sealing Material trop 50` Depth II. Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Pd REPAIR/ADDITION'r7 DESTRUCTION O INo septic system permitted if public sewer is - 'Z-•a_available-within-200-feet-,) Installation will serve: Residence L Commercial_ Other f Number of living units: . Number of bedrooms !t!� ' Mm Character of soil to:a`depth of 3 feet l /�o1gG— Water table depth SEPTIC TANK El. Type/Mfg pl'4,e Capacity No. Compartments PKG. TREATMENT PLT,,EfCtG7bt/KliNr _i _., Method of Disposal 11 /Distance to nearest: Well Foundation Property Line LEACHING LINENo. & Length of lines' `llJ"a. fry Total length/size AC1�7t7 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth I� Size`_ Number SUMPS ❑ Distance to nearest: 611 Foundation Property Lines DISPOSAL.PONDS ❑ 't'r 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."Contractors hiring or sub-contracting signature certifies the following:"I certify that in ttie_perfor4taance-of-the-work-for.which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." ` 1[ - The applicant must call for all re uired inspections. Complete drawing on reverse side. Signed X_ Title:Title: 1 Date: �'?w FOR DEPARTMENT USE ONLY Application r1 121. 9-Accepted by iF r9- Date z—1S_ Area d Pit or Grout Inspection by Date �FnaI 1 pectiGn_by '�zzr ✓/ �9/�� Date .2-.2 �S Additional Comments: II �' '�. O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 — ❑ Tracy` 835-6385 T Applicant- Return all copies to: Environmental Health Permit/Services 1601 E:Hazelton Ave.,P.O. Box 2609, Stk., CA 95201 FEE INFO �MOU(NT DU�EI jlL AMOUNT REMITTED CASH RECEIVED BY DATE PERMICK T N0. .. +EN 13-24 fREV.10193) E 14- H 29 f O