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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ? 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 Rules and Regulations of the San Joaquin Local Health District. Job Address l 129 W y S?'+ City ' A � Lot Size PM 8•L.�-c� 35D VVk--Ge* 1CKA,, APrtysi CJS- 9snb3 -2� Owner's Name Address Phon 4.,- wA0wA6 -- Sty rL 2*1i F-XQV-R MI�DI� {Za Z� G{ � 4533•S�b Contractor Address License No. Phone_ a TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP DISTANCE TO NEAREST: SEPTIC TANK SEWER C1SYSTEM LINESYSTEM REPAIR DISPOSAL FLD OTHER O( > �s6 P. LINE FOUNDATION AGRICULTURE WELL OTHER WELL /PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 Industrial ❑ Open Bottom 171 Manteca Dia. of Well Excavation Dia. of Well Casing �'df f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casin -4--CA f""Ed Specifications l`I Public P Other C1 Delta Depth of Grout Seal 4"S f Type of Grout—L— _. I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION ( I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) e—`' Installation will serve: Residence_ Commercial_ Other l Number of living units: Number of bedrooms y Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Co npts� C__PKG. TREATMENT PLT. 71Method bf o& IFFgy- Distance to nearest: Well Foundation Property Line RFnrou ED 1992 LEACHING LINE L1No. & Length of lines Total length/siz 31 FILTER BED ❑ Distance tonearest: WellFoundation Prop eyi 'n JOAQUIN COUNTY ,-�TH SERVICES SEEPAGE PITS I I Depth Size Number fhL NtALTH DIVISION • SUMPS 1=1 -Distan6Cto nearest' --W611—- - Foun'datiori' Pfopeity Line '"" -T ", 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 J 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 1 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 m or quired ins tions. Complete drawing on reverse side. Signe Title:c-ig4am�[ST " Date: FOR DEPARTMENT USE ONLY �J I Application Accepted by14, IAJQ�� r ` L. Date �` Area Ed Pit or Grout Inspection.by "tDate U r Z Final Inspection by Date Additional Comments: ❑ Stk 466-6781 © Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy a35-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 S INFO 49 FEE AMOUNT DUE (AMOUNT REMITTED CASH RECEIVED BY DAT//E, PER MIT�NO. +.EH13-24(REV.1/H5i x —/. l 1� � � `?Z Z EH 14-26 " r