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APPLICATION FOR PERMIT f 5 - SAN JOAQUIN LOCAL"HEALTH DISTRICT L6 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate)` _ 4' r 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. t '' r Sod -Al RAl- �b-w, ��o�¢`�`'. , Y 1. Job AddressCity Lot Size PM , � 9 27s— Owner's Name ;KAdre;s Phone �/ 11 b • Contractor el-11'M � 10 Qe�C 17$ ' woOA1K� ID �73�5� � of Ga�S Address License Ne.3_ Phone TYPE OF WELL/PUMP: NEW WELL ELL REPLACEMENT DESTRUCTION PUMP INSTALLATION 9 SYSTEM REPAIR ❑ OTHER ❑ f7,6 DISTANCE TO NEAREST: SEPTIC TANK —L r7. S LINES / S D DISPOSAL FLD. PROP. LINE FOUNDATION ULT_URE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /47 Pia. of Well Casing g Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications y ❑ Public " ❑ Other ,❑ Delta Depth of Grout Seal S t Type of Grout Ct/it�u 1 El Irrigation j-Lq-Approx. Depth El Eastern Surface Seal Installed by G Repair Work Done ❑ Type of Pump 3yK H.P. i� State Wo k Done Well Destruction ❑.,._Well Diameter Sealing Material {top 50.1e— k Depth Filler Material'(Below 50'1 GY?RLV- TYPE OF SEPTIC WORK: NEW INSTALLATION.EJ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is _ available within 200 feet./ Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: + P ": Water table depth 1 SEPTIC TANK ❑ Type/Mfg r Capacity,r j No. Compartments PKG. TREATMENT PLT. ❑ y + Method'of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No."& Length of lines: Total length/size Z7 FILTER BED CiDistance to nearest: {, Well - AI Foundation Property Line x,r. SEEPAGE PITS ❑ Depth # Size Number r t 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.; 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 California."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant �must .call lffor allrequiredinspections. Complete drawing on reverse side. ty Signed )Ll 7� /.(I►�drs� Title: OWP%A— Date: �"' 4-7 I FOR DEPARTMENT USE ONLY Application Accepted by Date Area ��Pito out"nspection by Date Final Inspection by , r Date Additional Comments: i ]"b �" I/v , ❑ Stk 466-Ml XLodi -3621 ❑ Monte 823-7104 f ❑ T cy 835.6385 Applicant- Return all c(fpi to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 1� ' ' FEE INFO AMOUNT DUE AMOUNT REMITTED j CASH RECEIVED BY ` DATE PERMIT-NO. . jE1413-241REV.1/e5) �, ��'�/ I — /Gs.�S• 3P~ "� EH 14-26