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rA APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—i ON AVE., STOCKTON, CA u Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED7 SEP 2 7 (Complete in Triplicate) iI I�sLapplication is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the vjaitjl�hli� mad."in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the a San Joaquin Local Health District. Job Address I f a City l...tx Lot Size PM r Ip i ! Phone Owner's Name Address �� ,- ter: l License No. Phone Canflractor r ,`y! �� r�� r''� ` Address r f tr - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ �M PUON YSTETCMEPAIR-n .OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK __SEWER LINES DISPOSAL FLO. i PROP. LINE FOUNDATION` _ + AGRICULTURE-WitL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LJIridestr�al• - ❑ Opert Bottorrr--- �-Mantece-----Dia:-cif-Nell-Excavation Dia of WA Casing Domestic!Private ❑ Gravel Pack ❑ Tracy Type of Casig Sp crfioati ins t p T pe of Grout t-1 Pbblic L! Other Cl Delta Depth of Grout Seal Ty'.e I 1 Irrigation Approx. Deoh l Eastern5u ace Seallinstalled by I - I State Work Doneff Repair Work Done L7 Type of Pump � � H.PJJ , - lea WellDestruction C3 Well Diameter �"`' Sealing Materf ;[tDp'5U') r'' Depth -� -� Filler-M�atenaAtie 0w-50'I TYPE OF SEPTIC WORK: NEW INSTALLATION { It REPAIRIADDITION l I DESTRUCTION,./ IrINo septic sysiem permitted if P-7 11c sewer is JQ y available within 200 feet.) installation will serve: Residence_ Commercial_ Other 1 ` 9 F Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ' a Water table depth I No. Co mpartments SEPTIC TANK ❑ Type/Mfg Capacity_ _... PKG. TREATMENT PLT. ❑ h Method of Disposal Distance to nearest: Well, ioundatioril P.roperty.Line p -Fr l a' r i Total-le-Alk/size LEACHING LINE 1 ❑ No. & Length of lines 1 li FILTER BED ❑ Distance tal�iearest�"'Weti-"- '"'""'�`"'"��Foundation Property Line SEEPAGE PITS i I Depth Size I _ Number SUMPS -� (---�^"Distanee�-to-nearest:-�-�'WeH--�--- —foundation r 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. Horne 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: '9 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's cornpensa- tior)' laws of California." a The applicantmustcall fear all required inspections. Complete drawing on reverse side. Signed X_F 1lll ii�1�l (_).P i�7�,_p Title: f l I_ r Date: ! 1 1 FOR DEPARTMENT USE f ONLY �3 r r �� Application Accepted by Date Area Pitlk 'or Grout Inspection by 1 l E+ �--Date Final Inspection by date Additional Comments: C]ajStk=466=6781==== E]zLodi--369=3621 ©Manteca--823--7904-•-----B--T•racy-835=6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK 0 4 I ' I P FEE 7 AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT NO. 49, JIII INFO +.EH 13-24(REV.i/H 5) ^_' 'rte....__• �I —7 0 .a EH 14-28