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S k APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 'i 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, J`4 (Complete in Triplicate) S, - 1, W 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 36 42— Ak?Avecity kA�L,Lot Size ! PM Owner's Name =Address /C) 630` 01?_IpfGrAe —S7— - Phon 14 Contractor Address License No. r Phan ��Z� TYPE OF WELL/PUMP: NEW WELL ❑ 'w WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION',: ..` ""'"""""""SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES ' t f DISPOSAL FLO. PROP. LINE FOUNDATION "AGRICULTURE WELL 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 Ll Domestic/Private O Gavel Pack. El Tracy Type of Casing f Specifications ' ❑ Public ElOther =0 1-1DeltaDepth of Grout Seal Type of Grout El Irrigation , pproz Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑: Type of�RiRnp Y'"� H.P. 1St-;a Work Done Well Destruction ❑ ,N7eIIrDiameter f ", Sealing Material Itop 50'1 1 �f `II W Depth` - Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR•/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) N ; Installation will serve:' Residence Commercial` Other' k Numbe of living units: Number of bedrooms_�—ti . 121 -Character of soil to a depth of 3 feet: 77! r Water table depth EPTIC TANK ' Ltr Type/Mfg v l Capacity 2b0 �' ,No. Compartments Method of Disposal PKG. TREATMENT PLT: ©+ 1-1, \1� ��, r A `� Distance to nearest:. -Well _ _ _Foundation_ l� � Property Line LEACHING LINE r ❑ No; & Length of lines aAkL i - Total length/size FILTER:BED. S , ° ElDistance to nearest: well Foundation I Property Line _ t�f I I SEEPAGE PITS m Ll o-Depth j� Size Q _# Number SUMPS Distance to nearest: Well'.W Foundation " ' Property Line DISPOSAL PONDS ❑ f`,40 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' signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not s employ any person in such manner as to become subject-to W&kman's compensation laws of California."Contractor's hiring or sub-contracting signature. certifies the following: "I certify that in the performance of thewvork for which this permit is issued,1 shall employ persons subject to workman's compensa i 1 i tion laws of California."7 �"—' � I The applicant must call for all requirg inspections. Complete drawing on reverse side. ' t1 t �'%�Y Title: Date: Signed X ` T,f,q:t 4 ' FOR DEPARTMENT USE ONLY _ i1 771& D Application Accepted by Date Area r Pit or Grout Inspection by ' Date Final inspection by Additional Comments: C1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Mariteca_ 823-7104 , � .�❑eTfacy'i 83576385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE ' AM6UNT REMITTED r" r SCK# RkVVED'BY� DATE PERMIT`NO. INFO ,.:fir '• ''- 5`5 + EEH13-241REV,7/a 5) ' ;��'S 3 ii.-�*{ ,- �-S� �O �� / ► /'&S . EN 14-26