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f . APPLICATION FOR PERMIT K. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 4661678 PERMIT EXPIRES'1 YEAR-FROM DATE 19SUED {Complete in.Triplicate) ""' ` ' LG'` 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 Local_Health District. >, F-1 ' ew y �. w_. W... _ r .ez lz�'.: k� Job Address `f- 7 3' f - a 17 ... ,, J City Lot Size PM Owner's Name 2— Addressx` `LL3 hone 3J�'/,;? Contractor Address Z A icense No. ��.3 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES DISPOSAL FLD._.,/p0, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i+ ❑ Industrial ❑ Open Bottom . ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r J$ Domestic/Private Gravel Pack Tracy Type of,,Casing pit✓ _—Specifications , ❑ Public ❑ Other ❑ Delta Depth of Grout Seal yp of Grout r E] Irrigation _Approx. Depth E3 Eastern Surface Seal Installed b i Repair Work Done ❑ Type of Pump H.P. Sta Work Well Destruction ❑ Well Diameter Sealing Material Stop 501 LA Depth Filler Material (Below 501 .r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_� Commercial_ Other W Number of living units: _max Number of bedrooms s j Character of soil to a depth of 3 feetr Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ .i ' r ! } Method of Disposal Distance to iieares£ Well Foundation Property Line LEACHING LINE 171 No & Length of lines Totallength/size FILTER BED ❑: Distance-to nearest: Well t Foundation -Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance,to nearest: Well Foundatfon Property Line DISPOSAL PONDS- Li_:,:- � t_ �. :�.,�-_ 2�"__ I hereby certify that I have prepared this application and that the work willtbe done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. t! A r Home owner or licensed agent's signature certifies the following: "I certify thatinthe 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 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." f The applicant ust call for all requi d inspections. Complete drawing on reverse side. Signed Title:' 4 ro .., Date: 2� ..FOR DEPARTMENT USE ONLY y Application Accepted by -�U grea D .rim r _a:� ,'"• -_,��. R` � u:� t� '4s�+'�,'�'�. Pit or Grout Inspection by; Date �G Final Inspection by Date l Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 <''O Manteca, 823-7104 'Ntl' racy 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 RECEIVED BY INFO DATE PERMIT".NO. I +EH 13-241REV,r/851 EH 14.26 3. 3_ r