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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209).466-6781 �N PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) _ I 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. 18622 for well/pump and the Rules and Regulations of the San Joaquin a J7S S- L10_>_? St,S /e,-r C71-, �I i Local Health District. � Job Address t 1-01 ` ML• l� - �� City Lot Size PM i Owner's Name 1. ,lJPif7,/ L al Address �7`7�3 L16W, lk-A /, hone 133 Contractor Address A.&da_1e cense No. 0290�/.3 Phone r TYPE OF WELL/PUMP: V NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ! DISTANCE TO NEAREST: SEPTIC TANK I1671P SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS L1 , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation .Dia. of Well Casing R Domestic/Private Gravel Pack XTracy Type of Casing pvc+ Specifications ❑ Public ❑ Other ❑ Delta W Depth of Grout Seal - Type of Grout ❑ Irrigation ---4pprok. Depth ❑ Eastern Surface Seal Installed by IMi !f Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION LLATION LlREPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence Commercial_ Other N { Number of living units: Number of bedrooms i 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 Distanc i ito nearest: Well Foundation Property Line I� LEACHING LINE ❑ No. & L1 gth of lines Total lengthtsize IC FILTER BED ❑ Distance,to nearest: Well Foundation Property Line I� SEEPAGE PITS ❑ Depth F Size Number I� SUMPS ❑ Distancejto nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 I� 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. it Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this per-mit-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 ,*®r cting si5nature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject man's comper�Ra- tion laws of California." The appliq t ust call for all requir iinspections. Complete drawing o reverse Sid . � Signed tl Title: r t Date: i• 2�r 4 FOR DEPART ENT USE ONL l Application Accepted by v J Date Ar e r Pit or Grout Inspection by Inspection y Perm Date � Fina! In coon b �@ I+ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy S D Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE _ INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. + EH13-241REv.liesl '7d.ov - f�Q� W ?5�8'b �Y1o57 EH 1428