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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) /Z j- f QD•-257 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. lr _ �1 f 1 C J4: ! �/ Job Address 6CT�B SG AN0 ( _ City 1115P r Lot Size PM owner's Name iQ� �'GNQ,_J_ Address P on 9) Contractor ED N C Address BMX UN lyfF—d .v 5 License f 0. Phone O TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j4iFsf.44.rc PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ;( :571/0 7'1-1401,E'S / DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 7"1/11 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _____ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing / ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public V Other dQ5F544XC t-I Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation .Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ O Well Destruction ❑ Well Diameter Sealing Material Itop 501 ,NA77�t W_F_ Depth _'S Filler Material IBelow 50') x" TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION f I (No septic system permitted if public sewer is available within 200 feet.) C Installation will serve: Residence_ Commercial _ Oth _C Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: Water table depth .4 ,SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size T Number SUMPS LI Distance to nearest: Well Foundation 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 laws, an rules and regulations of the San Joaquin Local Health DFstrict. 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 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." The applicant must call for all required inspec ns. Complete drawing on reverse side. Signed X. -,-/l�R.r,..,r��.—�! __.r... Title: fE��def Date: FOR DEPARTMENT USE ONLY Application Accepted by ` _ � Date —5- 17- 0"0 Area Pit or Grout Inspection by Dato Final Inspection b+�` Data _ : Additional Comments: ❑ Stk 466-6781 ❑ Lodi 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO. r.EH 13-24{pEV.I/x 51 � - r � �s 6� / L - 5-17 Z $ 1 EH 1429 rr