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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 0 1601 E. HAZEL T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 L PERMIT EXPIRES 1 YEAR 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. Jab Address / �L?/ C/4RA Citylyc,(/T/� Lot Size PM f , Owner's Name YJ/L S I � u� Addruss/74` C14/14 IV Phone 4177— 70 � +] f Contractor Coiij.Ir Yf/J",-;, rO Addres/, 0,& License No. l � '23 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT)< DESTRUCTIO PUMP INSTALLATION ❑ f 'SYSTEM REPAIR ❑ OTHER ❑ y, i DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES, O �' _ DISPOSAL FLD., /'t� L PROP- LINE FOUNDATION AGRICULTURE WELL, OTHER WELL PITSISUMPS� j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !I t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well-Excavation Dia. of Well Casing i Domestic/Private Pack ❑ Trac Type of.Casin � Specifications y g , F1 Public D Other fl Delta _Depth of Grout Seal' Type of Grout -� I r 41CL ce:_) 1t I I Irrigation a th I I st r f '-O�.Swface Seal Installed by Repair Work Done C7 Type of.Ru P. f, - ( State Work Done Well Destruction I] Well Diamet r Sealing Material (top 50'1 Depth Filler Material-(Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1, REPAIR/ADDITION i l., DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other, y f , Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth . SEPTIC TANK ❑ Type/Mfg �' Capacity No. Compartments 4 PKG. TREATMENT PLT. ❑ r Method of Disposal ~ �1 # Distance to nearest: Well Foundation` Property Line � t LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance,to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth. Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ -r- I hereby certify that I have prepared this application and that the wokwilt 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,'shall employ persons subject to workman's compensa- tion laws of California." r The applicant st call for all required inspections. Complete drawing oonnIreverse ide. ^.f { ' _ I VLZi�� -{ 'Al' l 2�_ y zTitle: (�( 9'! f Cl C/� - Date: L " � Signed X,{ - ! #� FOR DEPARTMENT,USE ONLY Application Accepted by Date��—�� Area Pit or Grout Inspection by (I;- Date` F ial Inspection by Date Q Additions! Comments: � � • �- ❑ Stk 466-6781 1-] Lodi 369-3621 Manteca 823-7104x` ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E-Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOU REMITTED CIC RECEIVED BY INFO DATE PERMIT'NO. i CASH ♦.EH13.24(REV.iin5) EH 14-26