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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) d 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 C�7r7'�L �� w ReP City la'Rc Lot Size - PM Owner's Name Heyde b,4 I✓f S Address 4614-% -dY•Y�r� `7OLLd l,t! `jC� Phone "-- Contractor'-� 0. l- _"�.jQ//P.. Address A0,02 License-No.- Phone �---- -- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHEWWELC— PITS/SUMPS _ j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i � ❑ Industrial 21 Open Bottom ❑ Manteca Dia. of Well Excavation Ilia. of Well Casing I� I ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing %:1 - ' Specifications F] Public . ;. (_l Other f Delta Depth of Grout Seal Type of Grout _ I I Irrigatipn �i __.Approxi Depth I') Eastern Surface Seat Installed by - Repair Wwk9Done 0 Type of Pump H.P. State Work Done_ A Well Destruction Ll `;1Nell Diameter Sealing Material (top 50') r I E _ — i ': _ ,Depth •� �`""-�""""� Finer Nlateiia! (Belo w 504I -=f' �•'_-- �4 ` TYPE OF SEPTIC WORK:! NEW INSTALLATION Ia REPAIR/ADDITiONAV DESTRUCTIONI I Mo septic system permitted if public sewer is a "? serve:;' i t available within 204 feet.) :' Residencee•� -1 yam. - Installation-will = / Commercial— Other Number of living units: Number of bedrooms Character.of soil to a depth•of 3 feet: to ,It - Water table depth SEPTIC TANK n c,'- "0!`Type/Mfg Av .4 � Capacityr/ 0ep No. Compartments � PKG. TREATMENT PLT: ❑ . Method of Disposal sd 111 µ Dist %to.nearest: 'Well l tG r Foundation JWP Property Line LEACHING LINE 0 No. $ Leng h,of 4ihes Total length/size FILTER BED ❑ Drstance`to nearest: Well Foundation Property Line SEEPAGE PITS I I IDepth Size . (f —`:Numbe „ - SUMPS ;.-. ,. r : f C� Distance to neatest: Well Foun. dation Property Line DISPOSAL PONDS ❑ t.. x'•;* t I ',s r; y w�p� fn, 4 } I hereby certify that I have prepared this application and that the work will tie done in accordance with San Joaquin county ordinances, state laws, and r rules and regulations of the San Joaquin Local Health District. • ` -" - -• `"k I.. . - • - . Home owner or licensed agent's signatuib certifies the following: "I certify that in-theperformance 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. 'Contractors hiring or sub-contracting signature certifies the following: "!certify that in the performance of the work for whicWthis permit is issued, i"shall employ persons subject to workman's compensa- tion laws of California." i .. - The applicant must call for all required inspections. Complete drawing on re i Signed X Title: cj 9� Date: FOR DEPARTMENT USE ONLY 4 Application Accepted by ACA &A Date Area f i Pit or Grout Inspection by Date Final inspection by Date a Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 I f ; FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT N0. 001001 +.EH13-24{REV.t i H 5f 5 � t0� EH 14-28 I