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F j . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 f7t��v-�. =L. City , 9 Lot Size PM t; Owner's Name ` Address 23505_ 11�1 L-("&L 10" Q C��yQz:_iPhone Contract t Address 1 l License No-3- 99a7a(0_ -Phone • `s 1535 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION ❑ F PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 I M FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i n ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing !I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I U ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 0 Irrigation Approx. Depth ❑ Eastern Surface Seat Installed by ' t Repair Work Done ❑ Type of Pump H.P. State Work Done r Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth filler Material (Belo 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI ADDITION DESTRUCTION-0 (No septic system permitted if public sewer is -Favailable within 200 feet.) InstaIIationwilfserve:"Residence C6mmercial "Othe"i Number of living units: Z Number,-of bedrooms - s Character of sail to a depth of 3 feet: ?'' Water table depth i(J� SEPTIC TANK ❑ Type/Mfg ._ ----r r Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' ` Method of Disposal Distance_To nearest: Well Foundation ""^'Property Line LEACHING LINE 2�-`No. &Length of lines q0 =t Total l�Length/size Y FILTER BED Cl Distance to nearest: Well Foundation Property Line .5 I SEEPAGE PITS R"'Depth —Size %3L22 _.- -.-!�,�„•; r -SUMPS 1 ❑ Distance-to-nearest:-. Well 4011,_ Foundation /0 ' _ Property Line .....__.__ DISPOSAL PONDS ❑ i I hereby certify that I have prepared this`applica_tioh 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 man ner`as-to-become-sdbject to workman'soorrlpensation laws of California." Contractors hiring or sub-contracting signature certifies the fa116wing: "I certy thatn t ifihe orma perf 'n`ce of the work for Mch this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The appiicantmust_call-for -required-inspections. Complete-drawing..on.reverse fside.e. Signed Title: V.i, Date: 61 FOR DEPARTMENT USE ONLY ) Application Accepted by P/4 •t Date I 6 U�( ' Area a Pit or Grout Inspection by Date 1— dYFinal Inspection by ' ��`' pate ~ I) 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3511 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT' 0. i.. INFO CASH + EH 14-281REV.31651 �� , EH 13-24 �T� 11tZ '��