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} APPLICATION FOR.PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 91n PERMIT E=XPIRES ,1'YEAR.FROM .DATEASSUED- a (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 Rules and Regulatiofls of the San Joaquin i Local Health District. . II . .�� ' 1 '-Vt::,% ,t,y ^T ��,55 Y'r r• '',2"!� �1�1' f`-C'� ��''. �i:' �{ xt.��:��"! RliE Y3.: 4t Job Address IV '""`^ C1 ...Lot Size 5 - PM Al _ "jt�"Address --Phone Owner's Name �A/.� _- _�� --� �-L-36;y0 Contractor's Nam ' J ., License No. 3 l -- Phone 3V? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ '""PUMP-INST7 L:IATION-O`—'" "'"'"'"'--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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other vvT--] Delta it Depth of Grout Seal �r Type of Grout 11 Irrigation ---Approx. Depth.. (]'Easte n + e.Surface Seal Installed by—_ 1s Repair Work Done [IType of Pump W.P. State Work Done N Well Destruction El Well Diameter Sealing Material (top 501 _ Depth A '' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION` REPAIR/ADDITION ❑ DESTRUCTION L1 (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence r''= Commercial '=Other' Number of living units: � Number.of,.bedrooms Character of sail to a.depth of 3 feet:. _ r� 15 Water table depth i �-' SEPTIC TANK 2"" Type/Mfg i Capacity IgLOD No. Compartments . PKG. TREATMENT PLT. Elj ' a �� ,.. I Method of Disposal 3y t f 'Distance'to nearest: 'Well 1�� L_ Foundation -�0 Property Line � - - - LEACHING LINE? Er'�No. & Lehgtfi of lines • • . Total length/size /Qd FILTER BED r ❑" Distance io'nearest: Well_..�.LL FoundationProperty Line _.. a. r� SEEPAGE PITS. ,) le D'epth�l Size 3r`. .f V ' Number SUMPS ❑ rDista ce'�to neari?st:^ 'Well 1 SO ' -F,oundationi 0 Property Line -5• �� DISPOSAL PONDS. ❑ \ f hereby certify that I have preparedithis application and that tR_e worts will be done in,accordance.with San Joaquin county ordinances;state law-s,—and t 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`yvork'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 Califorrna. •Colitractoes hiring or sub-contracting signature certifiss 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 11 required inspections. omplete_drawing-on rev�er}se�si}de. Signed �t` Title: V l, °.. Date: s �t;"^`r{ • 43 ^ 3 FOR DEPARTMENTUSEONLY Application Accepted by 1 �� _ Date FJR Area _..__ Pit or Grout Inspection by Date Final Inspection b � r €'l — Additional Comment- 4> — ❑ Stk 466-6781-41 Lodi 369-3621 ❑ Manteca 823-7104 � Tracy`+835-6365 Applicant- Return.all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 # LNtF.O' CK AMOUNT DUE' AMOUNT REMITTED ' ��CASH ""RECEIVED BYE DATE PERMIT N0. + EH 13-241REv.1018311 J O L71i "'- —� /� � •=� � S: EH 1428