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d APPLICATION FOR PERMIT tom' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA v i. e V 1, 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 Rules and Regulations of the San Joaquin Local Health District. Job Address o� City �^� Lot Size PM Owner's Name C CLARV---ddress 5610 E Phone Contractor ��I�fClr� Address /SO �t.��cl�1 Atfe License No. 2921rl 74 Phone "2A �$� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Aor " 'PUMP'INSTALLATION-0 SYSTEM-REPAIR--D------# OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE I j FOUNDATION AGRICULTURE WELL OTHER`WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 11 Manteca Dia. of Well Excavation j Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal f .. Type of Grout „ I ! Irrigation —.-Approx. Depth l I Eastern Surface Seal Installed by "V Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ . Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 {DESTRUCTION W (No septic system permitted if public sewer is 3 (_..— .. .'available within 200 feet.) Installation will serve: Residence __ Commercial_ Other � n�I c Number of living units: Number of bedrooms Y� Character of soil to a depth of 3 feet: Water table depth (\" SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ # f . Method of Disposal Distance to nearest: Well Foundation Property.Line ` •� f jh\ LEACHING LINE ❑ No. Length of lines Total length/size �} FILTER BED ❑ Distance to nearest:" Well Foundation 1 Property Line, SEEPAGE PITS I 1 Depth --Size Number SUMPS, ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS © ~x I hereby certify that I have prepared this application and that the work will be done !n accordance with San Joaquin county ordinances, state laws, and f rules and regulations of the San Joaquin Local Health Ditrict. '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 taws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the rformance of the work-or.which this permit.is issued, I shall employ persons subject to workman's compensa- tion laws of California." L- _ ._ The applicant for all required i pections. Complete drawing onreverseside. L Signed XCtVTitle: `-^�- 'T Date: FOR DEPARTMENT USE ONLY � Application Accepted by Date I dpif Area Pit or Grout Inspection by Date Final Inspection by �/�6i�� Date7�� Additional Comments: � ,0-Stk.:466-6781,.. _ -:Lodi-369-3621.❑-Manteca-823-7104-- ❑-Tracy-836-6395 Applicant- Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH ♦.EH 13-24 1REV.1/rt 51 4 66 X/a Z/7 EH 14-28 fl � .