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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 Ryles and Regulations of the San Joaquin t Local Health District. m Job Address Id's4 D0 City .S77,-A1' Lot Size PM Owner's Name gLlnA C,,R AX Address 6131 CLILgOEP_PE.e [syr Phone--- Contractor T� 't7 Address .. Zr9_ %LL%A.1J A4/E License No.54Y�Y_7,� _Phone -_7 TYPE OF WELL/PUMP: NEW WELL ❑ �} WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION_04a SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:-`SEPTIC'TMW -"77'T-SEWER-LINES DISPOSAL FLD. PROP. LINE N., : 'FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA '.CONSTRUCTION SPECIFICATIONS 17 Industrial A ,e, O-�Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 1 ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern I Surface Seal Installed by Repair Work Done _T.ype of Pump H.P. f State Work Done Well Destruction LlWell Diameter Sealing Material Itop Depth ? Filler Material (Belo '.W 5 ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system-permitted-if-public sewer-is SN available within 200 feet.) O Installation will serve: 'Residence_ Commercial_ Other Number of living units:_7— !Number of bedrooms 7-` `� T Character of soil.to-a-depth.of-3 feet: 11_� Water table depth SEPTIC TANK I ❑ Type/Mfg ` r' Capacity No. Compartments PKG. TREATMENT PLT. ❑ i d� Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE E< No.,& Length of lines illi4 '1 Total length/size FILTER BED } ❑ Distance to nearest: Well Foundation 2�el` Property Line --!C- SEEPAGE PITSi ❑ /Depth 1 O r 1 Size q Number q SUMPS : LIQ Distance to nearest: N Well SIA Foundation 10 / Property 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',Nand rules and regulations of the San Joaquin Local Health District. f '• 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 sucWmanneroas 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 f6r which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." f The applicant must call for all required inspections. Complete drawing on reverse side. { Signed X W� Title: Date: € FOR DEPARTMENT USE ONLY,�` f _ Application Accepted-byDate � /"" �� Area �' Pit or Grout Inspection by ate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 a ❑ Tracy 835-6385 Applicant- Return allcopiesto: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE' AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFO 1 r' ly7 �^ + EH 1&241REV.1/M D - r ��c r y U �/~ o 49 EH 14-26 } I/ 11