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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,. STOCKTON, CA r Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. [ 'i Job Address � � -" SCC��Ov! �d loll_ ld, City SCG�6 �� Lot Size PM ��.,� �>, � Owner's Name �1�V Y= -?s„ ,-�,Ute Address f 5YIE)6 Escodon � ..... 1 Phone Contractor Address License No. Phone ! TYPE OF'WELL/.P.UMP: t" NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMPilSTALLATION C1 SYSTEM REPAIR El OTHER ❑ DISTANCE TO`NEAREST: SFPTICkT-ANK- - _ SEWER LINES DItSPDS','C FL`D" PROP. LINE t FOUND _ "-� AGRICULTURE WELL OTHER WELL..-,_- PITS/SUMPS _ INTENDED USE TYPE-OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial I' ! µ❑ Open Bottom ❑ Manteca Dia. of Well Exca ation. . Y j Dia. of Well Casing g ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications t ` f l r V (1 Public y{ ❑ O"th*r f_-1 Delta Depth of Grout Seal 8 Type �. 151 Irrigation it --Approx. Depth I I Eastern Surface Seal Installed b"y� ew ! I f. i ,i . Repair�WorkAo9' ❑ Type,of-Pump H.P. State Work Done Well Destruction#I ~❑ Well_Oiam_eter Sealing Material (top 501 J DepthFiller Materia! (Below 50'1 TYPE OF SEPTIC'WORK: NEW INSTALLA ONPL REPAIR/ADDITION H DESTRUCTION I I (No septic system perfttitted-if public sewer is r available within within 200 feet) Installation will serve: Reside _ Commercial`_Other Number of livingiunts r"" Number of bedrooms Character of soil t � o a depth of 3'feet- Water table depth i i ; J "< SEPTIC TANK }©}Type/Mfg' Capacity No. Compartments " PKG. TREATMENT f�7PLJT.rt❑s tyethod-of-Dispose(~ Cr Distance to nearest: Well Foundation Lineoper T j 4 LEACHING LINE ❑ No. Length of line`s, Tptal length/size— FILTER ength/size FILTER BED � nl7 Distance to nearest: Well Foundation /(, _ Property Line ` ! SEEPAGE PITS )e Depth S1 Size d Nyu Ibar SUMPS {fir L] Distance to nearest:, Well Foundation��1�1 Property Line DISPOSAL:PONDS ❑ d � r 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 Lbcal Health DiArict. tI I . 4 Home owner or licensed agent's signature 8enifies-tho4ollLwing: "I.certify that in the performancl of the work for which this permit is issued,.1 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: "I certify that in the performance of the work foot which this permit i i'9'u "I sbafl'employ persons subject to workman's campensa- tion laws of California." Th must call for all required ins ti S. Complete drawing on reverse side. t I '-Signed.. ------r- - - ._ ttl � -- --- - - -Dater j R 4 F RTMENT USE ONLY y;. , .Application Accepted bye' �. I 7—� 0 g Date Area EPit or Grout inspection by Date Final Inspection by Date Additional Comritents: ❑ Stk 456-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E:t Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO.. a '13141REV.'t-/'N 'f- _ O ©� EH 14-28