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" APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA r 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 Ryles and Regulations of the San Joaquin Local Health District. :; _. Job Address ES City Lat Size S0 X 125 PM Owner's Name K6N -L�WQCIA 5111"P91S;ES Address� 700-5-3 —S-10Q0ZW4 - Phone' 7 Contractor S E Address_P.17. RDx 1450 STCM License No. Phone 6 9tpo7 TYPE OF WELL/PUMP: NEW WELL 13 -_-—WELL-REPLACEMENT'❑ dESTRUCTION ® �- +F PUMP INSTA-LLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SO SEWER LINES --DISPOSAL•'`FLD. PROP. LINE j FOUNDATION AGRICULTL IRE WELL -� OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C1TRUCTION SPEC IFIGATIONS i +• ❑ Industrial ❑ Open Bottom ❑ Manteca Dia:W#Well Excavation l s + Dia. of Well Casing= l I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy.f Type of E'a`sing I \ 'i Specifications w { ❑ Public ❑ Other ❑ Delta Depth of Grod Seal Type of Grout--- ❑ Irrigation _�4pprox. Depth ❑ EasternV Surface Seal Installed Wy 1 � s Repair Work Done ❑ Type of Pump H.P. I State Work Done I Well Destruction j11111 Well Diameterti w '� { t (rte Sealing Materia`l-toi0p 5 'i. Depth /+ Filler Material jBelow 50'# I TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION ® "DESTRUCTION A (No septic system permitted if public sewer is ' ,y available within 200 feet.) Installation will serve: ResidenceJL Commer`cial> Other 9 � Number of living units: fa Number of 6clrooms_' 'y Character of soil to a depth of 3 feet: Loam �z —Water table_depth, SEPTIC TANK. .1 f�. df Type/-Mfg Co�1C+t�� It �:� �� Capacity Ela 1 No. Compartments �- PKG. TREATMENT PLT.'❑' � 1_v.�f� � } � � Me#hod'df Disposal- ; Distance to nearest: Well 1 5.0 Foundation �L(2 � Property Line. 20� { LEACHING LINE ! No. & Length of-lines 1 = 4,e Total Ien'gth/size 4 O'e " FILTER BED ❑ Distance to nearest: Welli Foundation Property Line t SEEPAGE PITS 4 Depth i Size ' Number r< SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application-an&that`tff work wilI be done in accordance with San Joaquin county ordinances,state laws,a`nd--- rules and regylations-of-the San Joaquin Local Health District. ' r f .{ Home owner or licensed agent's signature certifies the following-!"l certify that in the performance of the-work--for._which"'this,permit is issued, I shall not r employ any person in such manner as to become subject to workman's'compensation laws of California."Contractor's'h'iiing-or sub=contracting signature i 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." y�6 3 ?3 ! �!' /I A The applicant must call for all required inspections. Complete drawing on reverse side. Signed )tcvt�S/ i—Title: J�'ia.h�1.v _ Date: x FOR DEPARTMENT USE ONLY Application Accepted by 4✓ Date s, Pit or Grout Inspection byDate Final Inspection by Date l F Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.;CA 95201 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATEp[- PERMIT"NO. + EH13-24IREV.i J'"�S EH 14-26 ' w