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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ✓ 1601 E. HAZE I ON AVE,, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' Vol 0'4s (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 i Local Health District.. t Job Address � �N.. (�lYYt City Lot Size PM WOwner's Name �f�-�'� Address ��• :37 Q.h�v. Phone • Lf Contract6Lte�r e 1 C7 Address (' License No.-32Y-,? G Phone 31-9'5-/G S TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ (� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Ll Manteca Dia. of Well Excavation Dia. of Well Casing t 1 V ❑ Domestic/Private ❑ Gravel Pack L1 Tracy , Type of Casing .� � Specifications ❑ Public y ❑ Other ❑ Delta Depth of Grout Seai ' jtiti Type of.Grout I 1-1Irrigation --Approx. Depth El Eastern Surface Seal Installed'by Repair Work Done ❑ Type of Pump H.P. State Work Done X Well Destruction ❑ Well Diameter. Sealing Material (top 50') Depth Filler Material Below <'` { 50'1 / i TYPE OF SEPTIC WORK: NEW INSTALLATION 'REPAIR/ADDITION ❑ DESTRUCTION D-(No septic system perniitted"if-public sewer is i ✓ pavailable within 200 feet.) Installation.will serve: Residence� .Commercial_ Other i.7 R 0 - �- �. �u.��°�-►Q;/� Number of living units: Number of bedrooms j 3 Character'of soil to a depth of 3 fee : - �f ? �.- t _ Water table depth I7O � yF",- � SEPTIC}TANKS 9K-Type/Mfg tea- Capacity�16&0 -7,Nb.,Comp rtQ; �� ' ice` PKG. TREATMENT PLT. ❑ i f """ -M6thod of�.DisposaI t-�' Distance to nearest: Well 140 FoundationPro " � party Lirie LEACHING'L-I_NE 2-"No. & Length of lines IQTotal length/size L3 X' FILTER BEDr ❑ Distance to nearest: Well� Foundation rf0 11Property Line b$7- � SEEPAGE PITS epth as: Size—_ LN ' 3 Number SUMPS i ❑ Distance to nearest: Well ` T Foundation /D Property Line 5' «r"' DISPOSAL,PONDS ❑ 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 persori 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." r The applicant must tali for alVe uired inspections. Complete drawing on reverse side. � - - - Y Signed - - �tTitle`'Tr T , Date: . � � P7 I { r FOR DEPARTMENT USE ONLY _ - . s Application Accepted by F a Date Area D Pit or Grout Inspection by . Date Final Inspection by Date � f Additional Comments: t ❑,Stk 466-6781 i ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Boz 2009,`Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'"NO. f INFO CASH + EH 13.24(REV.1%s 5) EH 14-28 1 �© ♦Q Q 71 •� 1� 1 J