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r 1 Ps 1IM > a, tc`°Rfi� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA � ..� Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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. f rr/— r k Job Address . /C7 S, � g /t,, / J / __. City S-lv'eeooAKtot Size Je'`LLe to.0'. PM I Owner's Name le Q 64 Address 3S- S&e!!K /y Phone r, Contractor Address LicenseNo. Phoned � t TYPE OF WELL/PUMP: ..NEW WELL WELL REPLACE ENT 71 ''DESTRUCTION ❑ v PUMP IN SYSTEM REPAIR C1 OTHER ❑. �Ofe,4,m 7X DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.'LINE �f- —FOUIVDATIONF_` .-AGRICULTURE•WELI-,-•-:!-�°— OTHER-WECL� ` 6 "=PITS/SUMPS- �.. INTENDED USE TYPE OP WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia: of.Well Excavation Dia. of Well Casing - Domestic/Private 19 Gravel Pack ❑ Tracy TypeofCasing e__ Specifications M Public fl Other ❑ Delta'` Depth of Grout Seal ! 21 Type of Grout__.._ �/keaee I I Irrigation. _Approx, Depth LI Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump --- 4,96 H•P. _ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 -" Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION IJ REPAIR/ADDITION 1.1 DESTRUCTION I I {No septic system permitted if public sewer is _ r available within 200 feet.) r^ Installation will serve: Residence ` Commercial��Other'="""""`"""'"' V' Number of living units: Number of bedrooms {- ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ • Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation . Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ElDistance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size _ Number Ll x^-Distance-to-nearest: `T=Well.-- KFoundation - Property-Line DISPOSAL PONOS ❑ i 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 Local Health District. i 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 shalt not employ any person in such manner as to become subject to workman's compensation taws 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 subject to workman's compensa- tion laws of California." The applicant must call for all r uired inspe ns. Complete drawing on revergeside. Signed X Title: „ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �� Area Pit or Grout Inspection b pe Y Data �� Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Appl' ant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Bax 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. + EH 13-241REV.i m 51 1� ��9 EH 14-25 –1) .'