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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA l Telephone (209) 466-67$1 PERMIT EXPIRES TYEAR 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. Job Address �� !S'/l�I. + � City Lot Size ` �G PM Owner's NameA 11 a ? -«.ai, f i• 'I UJ_�,.J �"s�!S/�I`5ft[► ddress ` r. Phone ,Q. 1- 4<gLicense No Phone `vim i Contractor C"y�L Address r TYPE OF WELL/PUMP: u NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ,❑, _ SYSTEM REPAIR ❑ :+ ' "' OTHM[3 I DISTANCE.TO'NEAREST: SEPTIC TANK wA' SEWER LINES"' .�. DISPQSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industriali ❑ Open Bottom ❑ Manteca Dia. of Well Excavation --'�� Dia.of Well Casing ❑ Domestic?Private ❑ Gravel Pack ' ❑ Tracy Type of Casing Specifications 71 Public ' F1 Other :.Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation -Approx. Depthr t,l Eastern Surface Seal Installed by _ Repair Work.Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 I Depth Filler Material (Below 50'i TYPE OF SPPTIC WORK: NEW INSTALLATION REPAIR)ADDITION ( l • DESTRUC.J�ON I I {No septic system permitted if public sewer is 1 'wrap' 'aacl rin5,-�- Tis tti=--'-"tI_,,=A�` available within 200 feet.) Installation will serve:Res enc' � mmeraal Other" aa� j Number of living units: Number,of bedrooms Character of soil to"de th `S (Bet —`� e *'*`'` P ..`r.� '''�"'; - Water table depth SEPTIC TANK } a —1. Type/Mfg apacity No. Compartments } PKG. TREATMENT PLT EJ Method of Disposal r t - - ♦a.. ♦��.. ,•mai c Dtstanca fo pearest .� .VVlellFoundation Property Line LEACHING LINE i y.,;. N,y: Le f li "" "'Z, f> P 4i ggt11w. eq§; '7 =- ¢? a�:,�Total length/,size FILTER BED, , t `pistance to nearest'� Weli �Fou'n�tiara., 4 Property Line � T SEEPAGE PITS ;N I 1 '-Drdptfi ^ Size Numhar S Ll Distance to nearest:`* �Welf "' 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 regulatibns-of the San Joaquin Local Health District, Home owner,or IIGef_sAd agent's signature certifies the following:,"I certify that in the performance of the work-for which this permit is issued, I shalt not employ any person'in such manner as to become subject to workman's compensation laws of California."Contrictor's hiring or subcontracting 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 CaliforAia.", The applicant must call for 11 required inspections. Complete drawing on reverse side. Signed X < _ k Title: -�•�/.a I �y I Date:'l r FOR DEPARTMENT USE ONLY Application Acee ted bYl Date-- Area Pit or Grout Inspection by Date Final Inspection by Date.,; � Additions! Comments: r ❑ Stk 466-5781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑'Tracy 835-6385 i ! Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I -. -,r-----.'was+- __-_-- _'__-._r -_.«.-----"�.�-..-.-.-.�.. _ .---.__— —_.--. .�crw.r•, +�r:wwr+'ax+::-C'�- FEE AMOUNT DUE AMOU T REMITTED CK k RECEIVED l3Y DATE PERMIT NO. INFO Q i CASH ` "+`EH-13=24-IREV:'!/n51 .. .., �[-.- _ .'rz'.�.'"""h^' - -•.•---... 'GHQ C / EH 14-28 (�!,J