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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 _ i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED • r (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 .7.2 J S7 City Lot Size PM r �$S Add. 1_2 3 y Owner's Name _ phone 2V,_ ContractortQ—gL&2A66e1eWB42 Address . ZA=.S License No. Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ M DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK A 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ` ❑ Irrigation --Approx. Depth ❑ 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 501 F' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION.0 (No septic system permitted if public sewer is available within 200 feet.) U1 Installation will serve: Residence Commercial Other J Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg IE'� �' Capacity No. Compartments ` PKG. TREATMENT PLT. ❑ f Method of Disposal Distance to nearest: - WeIIA, ZZ6 Foundation Property Line ((( . � LEACHING LINE ❑ No. & Length of lines I V P5 Total length/size .2670 FILTER BED ❑ Distance to nearest: Well iyf0 Foundation Property Line v � C SEEPAGE PITS ❑ Depth Size Number s SUMPS ❑ 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."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 m s cal o II required ins tions. Complete drawing on reverse side. E� Signed Title:_L fry � Date: _!"" 'yo— r FOR DEPARTMENT USE ONLY Application Accepted by Q /1 _ _ Date �'—3O —Area.___.D6 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: - �� l� lr�T 7T' e dr,V e 1.,G (Le L. ❑ Stk 466-6781 EI eodi v369-3621 "O Man 823-7104 ❑ Tracy 8354M ti 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 CK 1 RECEIVED BY DATE 'PERMIT`NO. + + EH10.28 V 3-24(REV. EH 1 F/&5) O 0 /� 0 g�"'1} 1 ' ✓✓✓ L/111 fff lr/ i