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APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED" ` {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 Ryles and Regulations of the San Joaquin Local Health District. a Job Address to City 914 oll `z'Lot Size PM ' . Owner's Name j Address Phone 170IU ContractorWr 41,f W-5A dress ,M0 1 License No. � + �1 Phone^ TYPE OF WELL/PUMP: NEW WELL _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INST_ALL4TION i 'SYSTEM"REPAIR-C] OTHER_L7 DISTANCE TO NEAREST: SEPTIC TANK Wit .t SEWER LINES DISPOSAL FLD. �` nP,ROP. LINE- �� I FOUNDATION i � AGRICULTURE WELL_Jjj�_°t OTHER WELL t --IPITS/SUMPS INTENDED USE TYPE OF WELL ( PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.:of Well Excavati n i �(A Dia.lof Well Casing 161G�1 Domestic/Private Gravel Pack E.Tracy Type of Casing SSd6d (Specifications Public ❑ Other ❑ Delta Depth of.Grout;SeaI t Ty e of Grout y ❑ Irrigation --Approx. Depth Eastern{ Surface�Seal Installed�by Repair Work pane" ❑ Type of Pump Sub H.P. �4_�..S4taatte-Work DVlI- Well Destruction ❑ Well Diameter `� Sealing Maerial {top 50'] w t'-,.. .a.z•# De Depth 16TO s " -, p Filler Material [Below 50'1 r ;TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION-2 --DESTRUCTION ❑ (No septic system permitted if public sewer-is. ` F # ,J available.within 200 feet.'1:•` ` Installation will serve:`"Residence Commercial— Other 1 t Number of living units:- Number of bedrooms— I l t # ` Character of soil to a depth of 3 feet: ; <+. }► � ' Water table depth I, 1 iSEPTIC TANK ❑ Type/Mfg Capacity Q No. Compartments 1 PKG. TREATMENT PLT. ❑ ' .� 3'' 9 ` ' S�;` ;1 Y i a `�t_ ,� , <. �ti ' ,i• 4� ,t Methodof Disposal % Distance to nearest: Well Foundation r l Prope`r'ty Liner LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well A' } t 1_ Foundation Property`Line I �g SEEPAGE PITS ❑ Depth Size` Number �. 3h,.v SUMPS ❑ Distance to nearest: Well Foundation Property Lme c DISPOSAL PONDS ❑ r t. 'r 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 'rules and regulations of the San Joaquin Local Health District. -rY Homeowner or licensed agent's ents si nature certifies the following:9 9 g: `9 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.'1Con_tractor's hiring or sub-contracting.signature r certifies the following: i "I certify that in the performance of the work for which this pe"rmit is issued, I shall employ.persons subject to workman's compensa- ', tiori laws of California." The applicant must call f IIrequired inspections. Complete drawing on revearse si l G- Signed \�'. S' Date: 1� FOR DEPARTMENT USE ONLY r Application Accepted by Date Ara 1 t Pit o Grout spection by Date �J 7 f=inal Inspection by Date Additional Comments: 1 E.I.Stk 466-6781 Lodi 369-3621 ❑ Manteca 8,23-7104 ❑ Tracy 835-6385 plicant- Return all co 'es to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 15201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY l DATE PERMIT`NO.' .1+ H 13-24 EH 14261pEV.r/s 51 1 0. ..1 �9�17 �^��