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¢= . - Y T ti tic? i Coje APPLICATION FOR PERMIT reSAN, JOAaUIN'LOCAL HEALTH DIStRIC_Tr ,j 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 uJaa� PERMIT EXPIR�ES'1 YEAR FROM DATE ISSUED ` (Complete'in Triplicate) ' ''E 4 t .,< , ;, ' t ' y ! 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. �-; ' 3 Job Address 34411 CytiTn1 ] C{gyp r city,-TiCr�1 's , Lot Size 2(� AG QPM` .5301 Owner's Name _�A_�—��il-L: - Address 3 rf �ovNT� ." �✓ Phone voo Contractor P.ro•S S,;"W4 Address Soft ISa,I License N67,5q_ 343 Phan,A( -56o7 � 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial ❑ Open Bottom Ll Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel.Pack ❑ Tracy .Type of Casing Specifications ❑ Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done r• Well Destruction ❑ " Well Diameter Sealing Material (top 50') Depth Filler Material (Below 601 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION X (No septic system permitted if public sewer is available within 200 feet.) . f Installation will serve: Residence_-- Commercial_ Other Number of living units: .1 Number of bedrooms 4 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 0 No. Compartments PKG. TREATMENT PLT. ❑ Method of.Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE -" ^"❑ No. & Length-of lines Total length/size FILTER BED ❑ "Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application 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 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: ECT"- +L- Date: r g� tFOR DEPARTMENT USE ONLY J Application Accepted by' r Date Area ` dkLLk`1a " Pit or Grout Inspection by Date Final Inspection by � o,r�s � Date Additional Comments: �`�^ � SU�c�tytS�o � s�^FS CaC)c) r'e5S �a ,�� • ❑ 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: IFEE NFO' AMOUNT DUE i AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-24IREV.1/e 51 F b—�–`ZS EH 14-28 �.J