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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL`HEALTH DISTRICT w 1601 E. HAZE-TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES°1`YEAR'FROM DATE 1SSUED " {Compiete'in"Triplicate} 4.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. +L,+ " . - " .F.: .v ....;W. i __ - Job Address C Q�� u/-Y [ �Lf17�1' <C7( 'r ^">' I era <.ia City } "ISA'Lot Size 1 2 0 ' PM Owner's Name Address O LJ, -C�Yti� f Phone Contra cto ��Address Y�, Jcrx_11, License No. a(A Phon G' —Srf TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ s SYSTEM REPAIR, OTHER{❑ 'DISTANCE TO NEAREST; SEPTIC TANK i SEWER LINES. DISPOSAL FLD. PROP. LINE �t j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation— Dia. of Well Casing ❑ Domestic/Private ❑ Gravel!Pack ❑ Tracy 'Type of Casing Specifications ❑ Public ❑ OtherElDelta 4 Depth of Grout Seal Type of Grout I 11Irrigation _..--_.Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done f f Well Destruction ❑ Well Diameter 3 Sealing Material (top 50') IU Depth .Filler Material (Below 50) I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI /ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is s I } $ f uJ available within 200 feet.) j Installation will serve: Residence! Commercial x Other r Number of living units: Number of b rooms ? �i t Character of soil to a depth of 3 feet:^ b Water table depth r SEPTIC TANK ❑ Type/Mf I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance io4nearest: Well s—Foundation- Property Line LEACHING LINE 9--No. & Length f lines l � ^' Total length site U ' FILTER BED ❑ Distance to nearest: Well_y� ._- Foundation /D Property Line—s�_L_ l SEEPAGE PITS ❑ Depth, > f Size V "' T x iNumber Ir �. I SUMPS Ll Distance to nearest: Well Foundation f Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be,dbne in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District' 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 employ any person in such manner as to become subject to workman's compensation laws of,Ca lifornia."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." } The applicant us t call for all requ7ed inspections. Complete drawing on reverse side. /j �y Signed // a Title: V 1 r Date: `� /�� IS �— I FOR DEPARTMENT USE ONV/ Application Accepted by ¢ DateArea77 ��Ja Pit or Grout Inspection by S Date Final Inspection by Date `3 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 I IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 13Y DATE PERMIT-`N0. + EH 13-24(REV.I/a5) .r - EH,428 -7'7` c�p �� !R b -I 75�