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N APPLICATION FOR PERMIT SAN JOAQUIN LOCAL:HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE "ISSUEDI'll ° (Complete in Triplicate) ' ; " s• w :') 'J.3. r of . . - 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. =� / �f's:�r-• f � ,C,ci '�:3y' s'4rvT4s�� - .,. ; Job Address �S� /a + 9+i' „ , !%'�/�C ,t ». ._ 41--t . A a� �} City G Lot SizePM `;,-Owner_'s_Name_ _.—;_ _ -----Address Phone ontractor L Address /��'� ___" �_�— "v- Licens€�'N -,.._..M�._.-..,.._.,�.., �.---�^- -- "' ' �,'6�,�d e�i . Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1711, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑, IISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL(FLD. PROP. LINE FOUNDATION AGRICULTURE WELL d OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation _ Dia. of Well Casing ID Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications © Public ❑ Other ❑ Delta Depth of Gr{out-Seal- -- __14 Type',of Grout f' IrrigatiorApprox:Depth❑"Eos#ern_" .Surface..Seal Installed by. fiepair Work Done ❑ Type of'Pump H.P. State Work Done ({Nell Destruction ❑ Well Diameter Sealing-Material,(fop 501) ; Depth Filler Material Below 501 TYPE OF S PTIC WORK: NE`W-INSTALLATION- --REPAIR/ADDITION-❑---DESTRUCTION-']-(No eptic system permitted-if public sewer is °t _ available within 200 feet.) Instaliatin will serve: Residence J� Commercial Other I Nurn6et of living units: Numberpof bedrooms_ r� Character of soil to a depth of 3 feet: Water table depth C9 S SEPTIC TANK C Type/Mfg 177 Capacity 424+7 6 L No. Compartments 41 PKG. TREATMENT PLT. ❑ j+� Method of Disposal Distance to ne,est: *Well Foundation o'�CJ Property Line &6 LEACHING LINE No. & Length of line§>—`4-- AV- lee FT _ Total length/size �ILTER BED ❑ Distance to nearest: Foundation D ` }_ 6 _ Property Line !�<L'1,C7- SEEPAGE PITS -ED-Depth- -= ---=Size Number l SUMPS r; ❑ Distance to nearest Well �Foufldation I Property Line i } DISPOSAL PONDS ❑ Ihereby certify that I have prepared this application and that the 6ork 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'I certifyjthat in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to becomessubject 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, I shall employ persons subject to workman's compensa- tion laws of CalifoWa." ` The applicant must call.for requ'ed inspections. Complete drawing on reverse 4 side! Signed Title: r Date: -S 3,0 xa— . - { 's- FORD_PA"I MENT USE;ONLY 1 � pplicatian Accepted by �� Date a " Area ` # jdd` Pit or Grout Inspe tion by Date t' Final Inspection by Date 3 i Additional Comments: l Y t O Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 t ti Applicant- Return all-copies-to:-Environmental-Health Permit/Services 1601 E Hazelton Ave., P.O. Box 2009, StK., CA 95201FEE CK 4 t INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE i PERMIT NO." a ` r; + EH 13-24(REV.t/a5) - _ i t EH 14-26 /�� t _S-14 ti R