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3 APPLICATION FOR PERMIT 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) 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 31,99 E e Cd l f] !eY ��? City /C O w Q Lot Size PM IF Owner's Name3Q U Mc Caynick Address 3--( n A E. CO I jQd Phone `2 O ! Contractor +ft/ Addr,ss 5Q0 t Ort ,07tLicense No, Phone / y- I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR i1e' OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. � PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —"� JkITENDED 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 r 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth� �J�I 1 Eastern Surface Seal Installed by Repair Work Done C� Type of Pump ---.� H.P. State Work Done 4L r'rf 0 Well Destruction ❑ Well Diameter n Sealing Material (top 50') Depth JA k Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l I DLSTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial T Other Number of living units: Number of bedrooms PAYMENT N Character of soil to a depth of 3 feet: Water tab) SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i. PKG. TREATMENT PLT. ❑ Method o8sal 3 19 29 Distance to nearest: Well Foundation _ Property Line ENVIRG LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size _ Number Imo.. SUMPS ❑ Distance to nearest;; Well _ Foundation Pro e_ Line 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 Di%trict. 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 I 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 u t call for all requir inspec ons. Complete drawing on reverse side. Signed X Title: Date: { � O Q :1 ,I I _tRA DEPARTMENT USE ONLY l Application Accepted by "AwDate y Area !� i Pit or Grout Inspection by Date Final Inspection byL/ ��n .. Date '� I Additional Comments: ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Haielton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY DATE PERMIT NO. +-EH 13.24 1REV.I/H 51 EH 14-2e "'9 Sq i . _ a ...