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4710 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. Job q /� D, LO O4Q /7 d d,112MCA L City Jl7l� Lot Size _A ��i 7� PM - Owner's Address K q Owner's Name �� + Address � Phone Contractor &AVAle e©NS/ Address / ft J✓/�,�/� /1'tt Licns e N o. 4' (�C? Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK T— 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 FI Public Ll Other C1St�Maa "•' xt pf Grout Seal Type of Grout I I Irrigation —.Approx. Depth t I Eastern � Su&cAeal Installed by - s Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter SealingMaterial (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION X DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of I 4141 : 54 Water table depth 00' * ° SEPTIC TANK ❑ Type/Mfg' Capacity No. Compartments PKG. TREATMENT PLT. ❑ M Method of Disposal Distance to'nearest: 1g Whll, • a# Foundation Property Line ;r ' LEACHING LINE No. 8u_Lenath of lined ~`- Total length/size r •4 FkLTE BES' El Distance to nearest: @II SPD Foundatiorf Property Line SEEPAGE PITS M Depth -Sizes , ; 'Nurpber ` SUMPS Ll Distance to nearest: Well/1-1 -- Foundation/ 75 Property Line DISPOSAL PONDS ❑ . i• I hereby certify that I have prepared this application and that the work ill be done in accordance with San Joaquin county ordinances, state laws, and Q rules and regulations of the San Joaquin Local Health District. � " 6 Home owner or licensed agent's signature certifies the following: "I certify that R1 the r{nrmnce of the work for which this permit is issued, 1 shall not 4 employ any person in such manner as to become subject to workman's compensation Iof Caf�rnia."Contractor's hiring or sub-contracting signature 1 certifies the following:"I certify that in the performance of the work for which this permit is issued,Ishall employ persons subject to workman's compensa- tion laws of California." ,fe J,4. 11, The applicant ust call for 11 re ired inspections. Complete drawing on reverse siS Signed X �► �4�r r-�iN Title: �,r-+ s^ _ r, Date: F R 9,EP F',Ift E T USE ONLY` R ip �✓ • M Application Accepted by z,,, 9 t Date �^ Area Pit or Grout Inspection by _ Date Final Inspection by Dated �U Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 NsAanteca 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 YAMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. a EH 1 -20(REV.t x 5) EH 144-20 f i r+ �w ,3 Q_--