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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA ,i Telephone (209) 466-6781 PERMIT EXPIRES VYEAR FROM DATE ISSUE ' {Complete in Triplicate} Application is hereby made to t%he 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 Ryles and Regulations of the San Joaquin E Local Health District. w Job Address 710 �12 S'7 brs „�,. City $C/t��Lot Size / D X 20 o PM y i Owner's Name 41 X G Address / S T 41 fid Phone – a i Contractor_ CL/� ! �}� �N Address License No. Phone i TYPE OF WELL/PUMP: NEW WELL ❑" WELL REPLACEMENT ❑ DESTRUCTION ier PUMP INSTALLATION ❑ SYSTEM REPAIR [ID El �l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES,..,`% e DISPOSAL FLD.— PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRO BLEMAREA`"` CONSTRUCTIWSPECIFICATIONS___. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack C7 Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Deltak Depth of Grout Seal Type'of Grout ❑ Irrigation ___�Approx. Depth ❑ Easte, Surface Seal ralled by Repair Work Done ❑ Type'�of Pump l H.P. l� State Work Done 4 Well Destruction ❑.. Well Diameter ,v S alttng Material (top 50') Depth �L Filler Material{Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is II available within 200 fe'et.l Installation will serve: Residence_ Commercial Other A- Number of living units: !M Number of bedrooms Character of soil to a depth of 3 feet: a Water table depth SEPTIC TANK ❑ Type/Mfg i Capacity No.;Compartments ` PKG. TREATMENT PLT. ❑ I� ' Y "" Method of Disposal, Distance to nearest: Well Foundation Property Line l LEACHING LINE ❑ No. & Length of lines i Total length/size - i 1 FILTER BED ❑ Distance to nearest: Well' Foundation Property Line- 1 SEEPAGE PITS ❑ Depth Sizet Number SUMPS ❑ Distance to nearest:_ Welly Foundation Property /zine 1 DISPOSAL PONDS ❑ IA 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 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, 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 for which this permit is issued,I shall employ persons sdbject to workman's compensa- tion laws of California.' u ' The applicant must call-or all required inspections. Complete drawing on reverse side. Signed K I� Title: �/}4 ,�STTf / ,s<O K�-`'Q Date: G 8 OR DEPARTMENT USE ONLY E Application Accepted by; Date Area Pit or Grout Inspection !I Date FinalTrispection b Datez t_ Additional Comments: W 17� �-to kAri ij-w l O ha♦ YL,.v v i ❑ Stk 466 781 El Lodi l 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 FEE f AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE. PERMIT"NO. INFO a fp1 - +� S CASH e} i + EH13-2,4[REV.1/B51 _ F, d,s�f✓`3 1dZl.- irf/ -- Z�.`'s+ p Q1f��[J , EH 1426 ✓