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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT 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 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 ISS-3-9 Rd.Ir_44, City Lot Size PM ` Owner's Name Tom S ,4Te S _ Address S 6 3.� 03,4,-c6 o R i9 1110 All Phone 8�•'�� 6� .{ Contractor ��howY SvN; Address 680,7 BL ue v.�y /¢vG� Licerise,No. • Phone?;-'z3-v.Zf ' TYPE-Of`WELL/PUMP:—NEW-WEL•L"S --- ------WELL-REPI=ACEMENT p OES-TRUCTION,O'--- M- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/,SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca Dia- of Well Excavation Dia. of Well Casing F1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public Cl Other I ❑ Delta Depth of Grout Seal Type of Grout _ i I Irrigation --Approx.JDepth i I Eastern Surface Seal Installed by Repair Work Done C7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth 4�E Filler Material (Below 50) t> TYPE OF SEPTIC WORK: NEW INSTALLATION ["I REPAIRYADDITIONX DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet..) Installation will serve: Residence— Commercial_ Other l Number of living units: / Numdeer-of-bedrooms Character of soil to a depth of 3 feet, Poke Water table depth /d SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Methdd'of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Z No. & Length of lines �" dO ` t /Op " 9 Total length/size FILTER BED ❑ Distance to nearest: Well I14 , Foundation S Property Line 15' SEEPAGE PITS i l Depth -Sizet SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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-I rules and regulations of the San Joaquin`Local Health District. 1. Home owner or licensed agent's signature certifies the following: t g g g: "I certify that in the performance of the work for which this permit is issued, k 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons sufiiect to workman's compensa- tion laws of California." f t Ct The applicant mu t call for all required inspections. Complete drawing on reverse side.I J 11� A 11, t 1 r. y Signed X_ Title: i`f�;'. f faate:. F DEPA ENT USE ONLY i 3 Application Accepted by Date �'S �/�f Are Pit or Grout Inspection by Date Final Inspection by Date r F � y!s Y Additional Comments: i Je ❑ Stk 466-5781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i r FEE INFO AMOUNT DUE f AMOUNT REMITTED CASH RECEIVED BY DATE `PERMIT'NO. +.EH 13-24(REV.it n 5) EH 14.26 �+tA / 1 1p ,0 1 t�337 i 1