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\0 APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT V r 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED I (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 I' 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 l Health District. Job Address r 131?•4 a F0 RI> City � Lot Size 7 1 � 16� PM Owner's Name&SLL }�1 E 1 C1 Address. Phone '�^�S+v3 ' Contractor" y Address - License No. Phone TYPE OF WELL/PUMP:. _ NEW WELL ❑ WELL REPLACEMENT ❑ -,. DESTRUCTION ❑ _ PUMP INSTALLATION F1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTICTANKSEWER LINES DISPOSAL FLD.`'"-�""'"-PROP. LINE FOUNDATION GRICULTURE W L OTHER WELL a PITS/SUMPS _ ` INTENDED USE TYPE OF WELL PROBLE AREA_:. C_0 TRUCTION SPECIFICATIONS -° Ll Industrial ❑ Open Bottom' "" ❑ Mantec ia. of Well Excavation' Dia:-of'Well-Casing ❑ Domestic/Private ❑ Gravel Pack [01 racy Type of Casing Specifications M 1 Public t l Other ❑ Delta Depth of Grout Seal Type of Grout { I i Irrigation �_Approx. Depth l I East Surface Seal Installed by Repair Work Done- ❑ Type of Pump H.P. State Work Done_ I Well Destruction ❑ Well DiameterSealing*Materia p 50') 27' Depth Filler Material (Below 501 TYPE OF.SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1.1 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_`Other;, n - s,. Number of living units: - Number of bedrooms y }� -Character of soil to a depth of'3 feet: Water table depth SEPTIC TANK - ❑ T e/Mf --� — - _ -- - . . . ..` YP 9 Capacity _No. Compartments PKG. TREATMENT PLT. EI.- r Method of Disposal y Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. R Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number ' SUMPS ❑ Distance to 6earest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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, I shall not t. employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature i 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 applic ust call for all requ' inspections.Complete drawing on reverse side.• - Signed Title: AZ0'164- a U ..._ Date: Al FOR DEPARTMENT USE ONLY Application Accepted by ` Date 4�' � Area .. I Pit or Grout Inspectio Date �/ Final Inspection byklkll �— Date AdditionalComments: Y Id_S o f I'l r f' 1 - Z ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0-Tracy 836-638 w Applicant-- Return all copies to: Environmental Health Permit/Services 1601 E.-Hazelton Ave., P.O. Box 2009, Stk., CA 95201 -• FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED 9Y WCASH IT DATE PERMN0. EH wry{ � i EH 14-26 GREY.-i i n 5l ✓ V.�. _ A � r7 T(�� ! V f—3-0