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APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA , �v Telephone 12091 466-6781 4, %3 PERMIT EXPIRES TYEAR FROM DATE ISSUED ' � rk�tVPq y (Complete in Triplicate) SR1y�y�G,��Q44 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This apricatlon 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 •_rnK�'�� — City Lot Size PM �! r G `�C� f LAddress v 7r`z' ��/dt" n�► ✓+ �Ytt Cts Phoney -5)S, �343,to Owner's Name - r Contractor 5e Address License No. Phone TYPE OF WELL/PUMP: ..NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES " DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public 17 Other Ll Delta Depth of Grout Seal.. Type of Grout I 1 Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State"Work Done Well Destruction CI Well Diameter Sealing Material Itop 50'7 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTIONX Mo septic system permitted if public sewer is available within 200 feet.) I j w Installation will serve: Residence_' Commercial. Other �// S-V/t C 1�' 1-{'�5Lw' B'T7 X 11.144 'w /� W Number of living units: Number of bedrooms {,�/ y `!t 5' Character of soil to a depth of 3 feet: —Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No- Compartments PKG. TREATMENT PLT. ❑ _. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number ��:?SUMPS+F.. L Distance-to-nearest: ;o-+Well- = =—:Foundation-— P.ropertyLine------: 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."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." a The applicant m c for all require ns ;As. Complete drawing an reve e. Signed X X .� _ Title: X ate: X ^/ 40, FOR DEPARTMENT USE ONLY Application Accepted by A4 Date, Area .'" Pit or Grout Inspection by Date Final Inspection by / Date Additional Comments: r Z Z2 s ` � l e-4& J"'�'''o� 5,°o4y if ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 a.+A" /j'?qr Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 n 4 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BYE;DATE PERMIT'NO. INFO J� 7/ + EH 13-24 iREV.'I K51 �� ,(/ /��. � EH 14-26