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L APPLICATION FOR PERMIT ' s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) D&S— f)2-e A 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. t-7-72,6 _o= 44 4,9�, )Gy C� r Job Address LR f City 6 Lot Size 4tcAorS PM Owner's Name �aR r Addres 1&0 E. 44�""""',, rl "�� Phone��r ContractorilV' 'YPE �►rf !j �Addre l.eIt"I l'� i � �5WW License No,376V/5 Phone q f"� TYPE OF WELL/PUMP: NEW WELL ❑ 'I WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ I SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL( ►"i OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AEA CONSTRUCTION SPECIFICATI974irr ❑�Industri I A �❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domesti11 c/Privates i ❑ Gravel Pack + '-❑ Tracy - • Type of"Caging—�� !� pecifidations 1-1 Public Ll Other Cl elta Depth of Grout Seal +� f ype of Grout> cE I I Irrigation t ApprOx�Depth ►IT Eas e_rn Surface Seal Installed by Repair Work Done L7 Type of Pump) H.P. State Work Done _Well Destruc ion Well Dia to Sealing Material [top 50'1 _ ✓z-i Ar 170� 151 Zt.�l Depth L l 4 Filler Material l6elow 50'1 �� _ TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION E I DESTRUCTION i I (No septic system permitted if public sewer is Rl.:�u^' N vx"N available within 200 feet.) Installation will serve: Residence_ Commercial_ Other + Number of living units: Number of bedrooms � 1 Character of soil to a depth of 3 feet: • t Water table depth SEPTIC TANK ❑ Type/Mfg Capacity4.nNo. Compartments PKG. TREATMENT PLT. © fejt Method of Disposal Distance to nearest: Well Foundation- Property,Line_ x+ c LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line %,l SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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."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 laws of California." The applict corltr all required inspections. Complete drawing on eversefside. (CQ Signed X Title: C�.�Co 'r A C Date: T FOR DEPARTMENT IJE ONLY Application Accepted byq&/ Date Area ' Pit or Grout Inspection by Date 7 X Final Inspection b Dater Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 523-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 INFO AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY /DATE )�� PERMIT NO. + EH 13-24{REV.t/H 5l {, '— S / � -7/Z(/!� 7 EH 14-29 J ( 1 I Q �'�