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APPLICATION:FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,,STOCKTON, CA Telephone{209} 466-6* , PERMIT"EXPIRES 1 YEAR FROM',DATE'ISSUED h , (Complete in jripiicatelllir`, .i..w. ,. .t, F 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 - .__ �1,^y' +q IlR! F :e. �'.i..r� :" L,if - i •n , _.' - /" A Job Address �U }" City Z/o4I` Lot Size ? PM Owner's Name __(�(.�� L� .; ! � Adaress' Q CJ�IJ �c/l C.r --� :Phone ContractorU1.f&xAddress p � License� .►� U' No � — ,?_2� PhoneL TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR-El--� OTHER-❑ DISTANCE TO NEAREST: SEPAC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS F INTENDED USE TY OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Opbn Bottom ❑ Manteca.: v Dia. of Well.Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t ❑ Public ❑ Other f ❑ Delta• ; Depth of Grout Seal Type of Grout ❑ Irrigation --L-Approx. Depth ❑ Eastern Surface Seal Installed by Repair�Work Done ❑ Type of Pump H.P. State Work Done f Well Destruction ❑ Well Diameter Sealing Material Itop 50') i � t Depth! Filler Material {Below 501 r' TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIWADDITIONy DESTRUCTION ❑ INo septic system permitted if public sewer is Jia i s � X available within 200 feet ) f lot ,.! .` �1 Installation will serve: ResidenceCommercial�..�'4,:Other- � _ gel. � i Number of living units: 4_'Number of bedrooms.; e T � Character of sail to,a depth of 3 feet: _ �'✓ �_a4XL, ;: ^^�°-�� Water table depth Z6 '- SEPTIC TANK `fi Type/Mfg t i Capacity _V2 No. Compartments i PKG. TREATMENT PLT.❑ �� --. Method of Disposal Distance to nearest: Well _..Foundation SO !-¢ 'Property Line LEACHING LINE '4`No!& Length of lines.. .'7C) Total length/size /' J FILTER BED ❑ Distance to,nearest:'�Well � Foundation _67_10"OfV Property Line �� SEEPAGE PITS ❑ Depth s� Size Number ' SUMPS., ,❑ : Distance to nearest: J Well f tti XFoundation aProperty Line DISPOSAL PONDS ❑ +` I hereby certify that I have prepared this application and that the workrWill be'done`in accordance with San Joaquin county ordinance`s, 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 shall not l rnT employ any person in such manner as to beconie'subiect to"workman's compensation laws of California."/Contractor's hiring or sub-contracting signature C�)" k 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 r!99wjed inspections. Complete drawing on reverse side. °r Z I I Signed X Title 1 Date: FOR DEPARTMENT USE ONLY `7 Application Accepted by Date ^✓ Area I Pit or Grout Inspection b #.?- L to Final Inspection by 1 Date OA Additional Comments: �4 � �� t c"^10-Stk 466=6781` C7'Lodi"369-3821 anteca 823 7104 ❑ Tracy 835 6385 c� -Applicant—RetumTall-Copies to:'Efiviranmental Health 1fi01 E. Hazelton Ave_P.O'Box 2009, StFEE k.,_CA 95201 l INFO AMOUNT DUE AMOUNT REMITTED C SH 4 CK 4 RECEIVED.BY t• a DATE PERMIT'NQ. 00 + + EH13-24JREV.lies/ O �p/� �? EH 14-28 / If -