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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 TYEAR 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 Rules and Regulations of the San Joaquin Local Health Oisvi 11 iCL L IN e Awt, Job Address y51Mon e_r AeceSs Road F, Ofs'14 ty rI On. Lot Size PM Sirs s ' Las Po, � e4 Owner's Name �:f� Address - Phone i Contractor pltC�7ef"�I!',i+�Iir Address r )019( i �TT _ License No��✓3~OL� one TYPE OF WELL/PUMP: I� EW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REP61R Q OTH5R,,XNan1,A� Ir/ DISTANCE TO NEAREST: SEPTIC.TANK 1Nt+ SEWER LINES >l00 DISPOSAL FLD100 PROP. LINE 5 FOIUNDATION /q? AGRICULTURE WELL __!'!. OTHER WELL»ffo PITS/SUMPS N� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F �,�j El Industrial C1 Open Bottom ❑ Manteca Dia. of Well Excavation Zo— n Dia. of Well Casing S*7c I: ❑ Domestic/Private ❑„Gravel Pack ❑ Tracy. Type of Casing f Specifications f"1 Public j f_�1 g03her ❑ Delta Depth of Grout Seal d Type of Grout I I Irrigation f _Approx. Depth I I Eastern Surface Seal Installed by E Repair Work Done ❑ Type of Pump H.P. State Work Done - Well one _Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION [ ] (No septic system permitted if public sewer is 'I�� available within 200 (eat 1 Installation will serve: Residence_ Commercial_ Other Number of living units: J Number of bedrooms n Character of soil to a depth]of 3 feet: Water table depth , 4 SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments *�J E PKG. TREATMENT PLT ❑ Method of Disposal V I Distance to nearest: Well Foundation Property Line ¢^ _ v 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ ' Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS L-i I 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 rules and regulations of the San Joaquin Local Health Dstrict. Home owner or licensed agerii's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ.any person in such manner as to become subject to workman's compensation taws 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 subject to workman's compensa- -tion laws of California." ISM. The applicant must call for ailrequired inspections. Complete drawing on reverse side. . � Signed X C ' 1. 9_eaC' _ _- Title:��/�G�� "' � � Date: U DEP R NT USE ONLY f t Application Accepted by Date J ea r Pit or Grout Inspection by Date� Final Inspection r Additional Comments: I� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6386 Applicant- Return all copies Bio: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAM'IOUNT DUE AMOUNT REMITTEDH RECEIVED BY DATE PERMIT'No. INFO EH 13-24 IREV.r/n 51 III � �+�+<{ r � / ''I If� � FH 14-26 e_ 1- Ir"ff r) fir O• 1 �'PlrCanrt is es'f� s C � �° ` ' -