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t � a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made tolthe 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 J 1 City 41,6 Lot Size PM R 1rC y Tai [t76� Owner's Name 14 - .I U }� Address / Phone Contractor s t, 5� ncAddress� Gd8 ,'�ravf � � License Na. 6 ` TPhone 1 TYPE OF.WELL/PUMP:,;,_,,,,��.,. NEW.WELLD— __WELL REPLACEMENT, ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE VZ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 f Y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0:Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' - Type of Casing Specifications❑ Domestic/Private Gravel Pack Tay.[ FI Public g f Other 71 Delta Depth of Grout Seal Type of Grout. � rl I Irrigation�.� �� "Approx. Depth i 1 Eastern r� Surface Sleal Installed by r _ -Repair Work Done C7 Type,of Pump H.P. State Work Dane E I F - 'Weil Destruction C] Well Diameter ' Sealing Material (6p-501. e x i Depth' Filler Material.18elow 501 -TYPE OF SEPTIC WORK: NEW INSTALLATION 111"REPAIR/ADDITION I I DESTRUCTION 17 No septic system'permitted if public sewef is-- available s-available Within 200 feet.) Installation will serve: Res idence ✓, Commercial_ Other R F Number of living units: ) Numbei of bedrooms f Character of-soil to a deptl, of 3 feet: > - Water table.depth _SEPTIC TANK l�''I'Type/Mig GU/l!G► e- -w _ Cap--it y �� No. Compartments ' t PKG. TREATMENT PIT. ❑ i I y^. r z.��Method of Disposal ! °r Distance to nearest: Well"4 Four dation�'� Property Line LEACHING LONENo. &_ Length of lines `F �` Total length/size �-�• I. FILTER BED ❑ Distance to nearest + Well D Foundation Property Line r SEEPAGE PITS' 111 !' Depth azo � Size rz Number SUMPS ❑ D stance to nearest: We11 Foundation /DO f ^Property Line 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 law`s, ands I rules and regulationsof the gan `Joaquin Local Health District. Is: 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 r" l employ any pei on in such r4nner 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,1 shall employ persons subject to workman's compensa- tion laws of California." rt j The applicant must call for all required ins )' ; f j pp� q pectrons. Complete drawing on-reverse side. r Signed X �l.,XIL�I -1 ��C �� -� `' Title,. -� ° Date: ' R.., FOR DEPARTMENT USE ONLY ; Application Accepted by I Date L `Z-rJ' F Area j. r r z /Pik or Grout Inspection by } Date k riinal Inspection by /� ate 9 V 1 v ' i Additional Comments: .R ❑ Stk 466.6781 ❑ Dodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies:to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK 11 CASH RECEIVED BY DATE PERIJ T'NO. + EH 13-241REV.t/nsl M r�C� X / 7 EH 14.26 , !f// VV ! ! ) '- II