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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Is CAdk A f � 1601 E. HAZELTON 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. p /] t Job Address ` 'f rrel �� City a% 61 'Lot Size � PM V--Owner's Name . Flo -5 + j-- 4 Address �{—AA0 a)_/• ---- Phone 2,& k — Contractor rV6i lam} Address ' License No. Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTE "PAIR ❑ OTHER ❑ # DISTANCE TO NEAREST: SEPTIC TANK WER LINES DISPOSAL FLD. PROP. LINE { L FOUNDATION AGR ULTUR ELL OTHER WELL PITSISUMPS CJI I INTENDED USE TYPE OF WELL PROBLEAEAN RUCTION SPECIFICATIONS r El Industrial ❑ Open Bottom ❑ MantWell Excavation Dia. 'of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracyf Casing Specifications ('1 Public n Other F1 Deltaof Grout Seal Type of Grout11 irrigation —Approx. Depth i I Eastee�Seal Installed by � Repair Work Done ❑ Type of Pump H.P. State Work Done_ \ Wei[ Destruction ❑ Well Diameter Sealing Material [tap 50'1' Itf r Depth Filler Material (Below 501 YPE OF SEPTIC WORK: NEW INSTALLATION ' REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_a Other Number of living units: a� g Number of bedr�ms Character of soil to a depth of 3 feet: _ -gfd.cf Ab�hL C., F Water table depth SEPTIC TANK Type/Mfg e Ll COOK{14-4. Capacity-4 No. Compartments PKG. TREATMENT PLT. ❑ 1 f Method of D�posal ' r Distance to nearest: Well_ � Foundation fQ. Property Line LEACHING LINE No. & Length of lines 3 )r V0 Tgtal length/size r FILTER BED ❑ Distance to nearest Well 160 Foundation. 10 Property Lin P SEEPAGE PITS ['.I - Depth Size Number 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 Di?;trict- ' Home owner or licensed agent's signature certifies the following: "t-certify that in the performance of the work for whicti'this permit is issued, I shall not r emio .an p y y 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." applicant must c for all requir in pections. Complete drawing on reverse side. r' Q Signed X Date: d 3F� DEPARTMENT USE ONLYI' _ IP Application Accepted b F' " �' r � pp P y Data a Area p Pit or Grout Inspection by . Dc.v ` Final Inspection by TA t `2 - j- J '' Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 . Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE �l INFO AMOUNT DUE AMOUNT,REMITTED' CASH RECEIVED BY DATE PERMIT'NO. lx i..EH 13-241 (REV.r n 57 �/ / r`�� F� EH 4-26 V