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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE. STOCKTON, CA Ef', Telephone (209) 466-6781 . , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) j jApplication 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. , � Y IW 1-�C� Lot site 0 1� S AC Pm Job Address � `� ' � City y ��— : Owner's Name C-i L-� S Address Phone Contractor LSE R L-T MALL- Address `�� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ JJ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION.❑-;r, SYSTEM REPAIR ❑ OTHER ❑ E DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i l la-lndustrial ❑ Open Bottom I ❑`MantecaA r`r Dia. of Well Excavation Dia of Well Casing ❑ Domestic/Private ElGravel Pack ❑ Tracy Type of Casing Speci cations ❑ Public ❑ Other ❑ Delta' �_i 6epth of Grout Seal Type of Grout ❑ Irrigation # ---Approx. Depth 71 Eastern Surface Seal Installed by �/; ,�.. �., .t ' 03 Repair Work Done ❑ Type of Pump H.P. State Work Done E Well.Destruction ❑ .•Well Diameter y " """ `Sealing Material (top 501 Depth r"""1 Filler Material (Below 501 I i TYPE OF SEPTIC WORK: °-NEW INSTALLATION p REPAIWADDITION U_-VESTRUCTION o septic system permitted if public sewer is 'r t + s R ; I. available within 200 feet.) - rw. - £ G Installation will serve: Res nce [ Coxmmerc�ah - -Other Number of living units: I Number of bedrooms 9 + j Character of soil to a depth of3 feet: I Water table depth I SEPTIC TANK 1-1Type/Mfg Capacityl -- No. Compartmerits PKG. TREATMENT PLT. ❑ I i P" Method of Di " o�sal i Distance to nearest: Well /�"_"Foundation,l 1-41l Property Line r`� LEACHING LINE &;_-N o. &6Length of lines _ r Total lengthlsize ' ii FILTER BED ❑ Distance to nearest: Well .Foundation Property.L'ine f�: D f^ ,a SEEPAGE PITS ❑ Depth j .3 _ Size ° Number P -SUMPS ❑ Distance to nearest: m /Vel1 Foundation - -.,Property-Line DISPOSAL PONDS El 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. E ! } 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 ca4ifies the following:"I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion of California." The applica ust tail fo all r wired ' pe ns. ornplete drawing on arse sid P. G Signed Title: Date _ 1 FOR DEPARTMENT USE ONLY �f /�} l Application Accepted by Date / /f� Area Pit or Grout Inspection by Date Final Inspection by Date fG Additional Comments: ❑ Stk 466-6781 1 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' 1 Applicant-,Re ur all-_copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE INFO AMOUNT DUE AMOUNT REMITTED R RECEIVED BY DATE , PERMIT NO. + EH13-24(REV.1/0 5) Q EH I426