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l APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephohe (209) 466-67$1 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. 4 F Job Address as`}�3'B �L�lS VICE i2` E City_ CA Lot Size 8d- Ala- PM i-L l Acct {n� e h �8lit `)0 C cI'A14 Phon� Owner's Name Address �2An,(s EfR-4C �l�iCC F Contractor d A1SYr Address ; e=_r 7-8 04 License No.q711k<T{ _ Phon� �l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION'❑ SYSTEM REPAIR'❑ OTHER'❑ J� 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 1'1 Public F1 Other, 11 Delta Depth of Grout Sea! Type of Grout--.-N I I Irrigation —:Approx. Depth I I Eastern Surface Seal Installed by Repair Work pone ❑ Type of Pump: - H.P. State Work Done Well Destruction ❑ Well Diameter 7 Sealing Material (top 50') Depth IFiller'Material (Below 50'1 •�— - ' TYPE OF SEPTIC WORK: NEW,INSTALLATION . REPAIR/ADDITION 1 1 DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence-y— Commercial_ Other Y / I, Number of living units: Number ofAAF bedrooms 3 l / Character of soil to a depth of feet: /ho R t�g�AC Water table depth SEPTIC TANK ❑ Type/Mfg ' 1 Capacity`2�QP�0 No. Compartments PKG. TREATMENT PLT- ❑ 1 Method of Disposal Distance to nearest: ` Well' '� �Foundatio'n f Property Line'` LEACHING LINE ❑ No. & Length of lines .+ Total length/size p " FILTER BED ElDistance to nearest: Well Foundation/� 4 Property Line _ SEEPAGE PITS I I Depth r Size`_ __ ___ Number SUMPS Distance to nearest: Well Foundation !00 Property,Line %© DISPOSAL PONDS ❑ u 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 DiMrict. t ^ 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 fi 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 app is t mu call f r Ift red inspe ns, Complete drawing on reverse side. r t Signed Title: ► Date: FOR DEPARTMENT USE ONLY Application Accepted by f raq 4zDate��Z Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: APID �� / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE3 )NFO AMOUNT DUE AMOUNT REMITTED y�GA5H {{ RECEIVED BY r DATE PERMIT NO. AT- a.EH 13-241A EV.I/K5) 0 �SD3 {f�'1 jA EH 14-26