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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT { i 1601 E. HAZE T ON AVE., STOCKTON, CA 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 246 7 IrAT—re—61 A V6� City ai/tJJ Lot Size_/l92(W o PM E Owner's Name la cx Address Phone Contractor's Name FL..n yi> Ls. LtJ`04 b License No. -1.71.� Phone 4169--37711 TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE LACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION ❑ S ST M REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:—SEPTIC TANK SEWLIN DISPOSAL.FLD. I PROP. LINE Cf) FOUNDATION AG CULT RE V4LL _ OTHER WELL ° PITS/SUMPS i INTENDED USE TYPE OF WVELL REA CO STRUCTION SPECIFICATIONS s iI ❑ Industrial El Open Bottom Mante a ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pac ❑ Trac T e of Casing Specifications ❑ Public ❑ Other ❑ D epth of Grout Seal Type of Grout ❑ Irrigation �pprox. Depth ❑ astern urface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 I Depth Filler Material (Belor 501 0 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION W DESTRUCTION ❑ (No septic system permitted if public sewer is 1r� available within 200 feet.) T Installation will serve: Residence Commercial_ Other Number of living units:-4— Number of bedrooms J til Character of soil to a depth of 3 feet: _ ,4 A Water table depth y i 1 SEPTIC TANK ❑ Type/Mfg ST/qua Capacity No.i Compartments PKG. TREATMENT PLT. ❑ Method of Disposal C), Distance to nearest: Well Foundation Property Line i i LEACHING LINE RR/No. & Length of lines �' _ Total length/size' 40 X FILTER BED ❑ Distance to nearestY t Well w/I-A 'Foundation Property line SEEPAGE PITS 9- Depth S Size 3 3 f f Number I rl SUMPS' El Distance-to nearest: -n Well- NIA :.Foundation Property 4Pne 10 " > DISPOSAL PONDS ❑ + r 3 I hereby certify that I Piave 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: 1 i Home owner ora 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 Calif ornia."Contractors hiring or sub-contracting signature certifies the.following:—"l 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." - r i The applicant must call for all required inspections. Complete drawing on reverse side. � f Signed X 2&&_42.._/ kA,.-rJ Title: 4 Date: /Z J } F DEPART N SE ONLY Application Accepted by Date ( ��G Area Pit or Grout Inspection by / Date Q� Final Inspection by # Date ? Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369 1 ❑ Manteca 7104 // ❑ Tracy 835- s /�✓' z� x Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EH 1324/REV.10/831 . la..f�.6. 3 �.3-1,3& i.EH 14-26—.. ..� -.- .. .._. �...