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a APPLICATION FOR PERMIT s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA �j'� �-L�>v�,N►,r�D PAY' Telephone (209) 466-6781 D ;PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in.Triplicate) Hca 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 Address `Xlae- 117,e0 ST n City Tim/ Lot Size PM Owner's Name �yEiQA�-Ofd/ �AJ�S AddressPhone 2-0147 Contractor Ta�LO 3/D G WOOD Address 4-0r AJ- Z.i LLI.A;U MCbcanse No.��76 . Phone— . &-CX7 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION, = AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA—CONSTRUCTIdN'�SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i i Dia. of Well Casing ❑ Domestic/Private 11Gravel Pack ❑sTracy Type of Casing t i Specifications ❑ Public ❑ Other f ❑ Delta Depth of Grout Seal`sem, ' Type of Grout ❑ Irrigation �4pprox. D+epth ❑,Eastern Surface Seal lnstalled'by 1 Repair Work Done ❑ Type of Pump 1 H.P, - State Work Done_ Well Destruction ❑ Well Diameter:t s; Sealing Material (top 50') t Depth j Filler Material (Below 50') P rf TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo•septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ 'Commercial i Other Number of livin units;_ '� Number of bedrooms - .. Character of soio a depth of 3—feet:,' eet: § if Water table depth SEPTIC TANK ❑ Type/Mfg ( I Capacity--;w E No. Compartments t - PKG. TREATMENT PLT. LlI ;` Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size....k FILTER BED ❑ Distance to nearest:. Well Foundation Property Line SEEPAGE PITS ❑ Depth t -Size + j Number f I ` I SUMPS ❑ Distance to nearest: Well _ �-�Foundation Property Line [ DISPOSAL PONDS ❑ A -43- 1 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 p rules and regulations of the San Joaquin.Local Health District; tr Home owner or licensed agent's si nature certifies the following 5"I,'corti that"in the performance of the for which this i 9 9 9�` fY Pe 4, permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this.permif.'is issued, I shall employ persons subject to workman's compensa- tion laws of California." i - i The applicant must call for all required inspectio omplete drawing on reverse side) r Signed X � Title: Date: T USE ONLY Application Accepted by Date ` Area Pit or Grout Inspection by 1 f Date Final Inspection by /7/ � Date Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621., ❑ Manteca-823-7.104,O Tracy--835-6385.4-r--7,- ,. Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 T1 INFO FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY. DATE PERMIT'NO. + EH 13-241REV.i/551EH 14-26 \j