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go 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 rnnCOYXA/w Mel-40W A$ City&A!! K Lot Size PM Owner'�Wame Rich.-ird A*,649�d_ Address .AN09B Phone vf'—A8� q L Contra 14or XIAA- OA/ .r YAW Address 401179 QGdC ✓A► AlIft, 35iclense No. '11✓iW—A/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL: OTHER WELL PITS/SUMPS 4 i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public n Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation ..Approx. Depth I I Eastern 'Surface Seal Installbd by # r Repair Work Done ❑ Type of Pump H.P. r ! State Work Sone_ k ! t'Fi Well Destruction ❑ Well Diameter Sealing Material atop 501 ty Depth µ� Filler Material (Below 50'i I TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITiON ' DESTRUCT19N I"Ilif�p septic system permitted if public sewer is .available within 200 feet.) w � ririI` f Installation will serve: Residence_a Gomm-eksral_ Other � Number of living units: Number of bedrooms Character of soil to a depth;of 3 feet: € iWater table depth SEPTIC TANK A Type/Mfg �7C� C4-4'r Capac4 J OC No. Compartments X pPKG. TREATMENT PLT, 0 {i Method of Disposat % f ;Distance to nearest: Well _ Found n �4�- �I „ �Litie, j t f+. Prpp�'rty LEACHING LINE ❑ No. & Length of lines �— �_ t�3 Fotal lenglotcie FILTER BED ❑ Distance to nearest: Well (r Foundation Property Line SEEPAGE_PITS .11 Depth 7 Size 1 ' ` +*umber f t ' SUMPS Ll Distance to-nearest:----Well—r Foundation7.4 Property Line DISPOSAL PONDS ❑ 1 P, E hereby certify that I have prepared this application and that the work will be done in accordance with`San.Joaquin c'ounry ordinances, state'laws, and L rules and regulations of the San Joaquin Local Health District. 0 1 Home owner Dr-licensed agent's signature`certifies'the following: "/ certify that in ihe-performance-of`the-work-for-which this�emtit-is issued;1 shall not' r d' employ any person in such manner as to become subject to workman's compensation laws of'California." Contractor's hiring or.sub-contracting signature r certifies the following: "I certify that in the performance of the work for which this permitis'issued, i shall employ persons.subject' to workman'§compensa fs tion laws'of California. a' !' 4,. The applicant mu t calt.for all required inspections. Complete drawing on reverse side. . Signed X Title.-,'. (# ! 01— FOR DEPARTMENT.USE ONLY ! application Accepted byB� M Date Area ' G� Pit or Grout inspection.-by Date Final Inspection by ate �,dditianal Comments: . , ❑ Stk 466-6781 ❑-Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy .835-6385 Xpplicant - Retu'rnall copies to: Environmental Health Permit/Services 1601 E. Hazelton AVq. .P.O. Box 2009, Stk., CA 95201 FEE t INFO AMOUNT DUE' AMOUNT REMITTED H :RECEIVED BY DATE- PERMIT'No. a.Ek 1 -24(RfV.r x b) I EH 1 -28 i t