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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL:HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED r I (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 44T I L. 44, rile City T Lot Size 17&9APM Owner's Name IN14eJ SAr2. Zepns,':F Address Y �s Phone— Contractor 442mS Address O , License`No.2S2472f2 Phone b tZ 'TYPE"OF:WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ V,' r PUMP INSTALLATION L1 SYSTEM REPAIR a❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKS R jSEWER LINES', DISPOSAL FLD. PROP. LINE %j11 t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSiR454. # ,.r INTENDED USE TYPE OF WELL PROBLEMEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Ll Manteca Dia. of Well ExcavationDia. of Well Casing ❑ Dome's'tic/Private Ll Gravel Pack ❑ Tracy Type of Casing ISpecifications ❑ Public ❑ Otte"her " " '"❑D`elDepth of Grout Seal Type of Grout i ❑ Irrigation\ �; pprox:(Depth ElE ernes Surface Seal Installed by _. : f Repair Work Done' ❑ Type of-Pump Wi ". Z H.P:. �. State Work Done Well Destruction, ❑ Well,Dhpmeter.'`- • i r. Sealing Mite,ial {t0'I""`�"—"s a op 5 .a r Depth "If I V1 ; }. Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0I DESTRUCTION / INo septic system permitted if public sewer.is V available within 200 feet.) Installation will serve:„ Residence_X_ 1Eom_mercial_�L Other .� 5 Number of living units:' Number,of:bedrooms,.` `-,,,I Character of soil to a depth of 3 feet: Water table depth 4 x SEPTIC TANK a Type/Mfg J_=3-6M1AAS Capacity O,,40 No. Compartments PKG. TREATMENT PLT. ❑ jJ , � � Method of Disposal M Distance td nearest: Well 100 i Foundation �a Property Line t1`lMEK 7 ' LEACHING LINE1, ■ No. & Length ofjlnes Total length/size 2 70 FILTER BED '.� 'Distance toF nearest: aWe'I_ loin Foundation Property Line O f SEEPAGE PITS ■ Depth 1i r Size _ Number SUMPS ❑ Distance to nearest:- Well- 1 O r / Foundation I©Q r Property Line Q f DISPOSAL PONDS ❑ f I hereby certify that I have preparedthis application and that•the_work wilkt;e done in accordance with San Joaquin county ordinances, state laws, andJ' rules and regulations of the San Joaquin Local Health'Districi. y t Home owner or.licensed agent's signaturecertifies 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 Workrri ih's compensation laws of California Contractor's hiring or sub-contracting signature certifies the following::"I certify that in theperforme ancof the s iorksfor which this permit is issued,I shall employ s k � ., p y persons subject to workman's compensa- t tion laws iif`California.." .1w The applicant must call for all required inspectionsComplete drawing on reverse side. 1 -..r}. 4d Signed'X ^�-- t'+ Title: - - 14-8 :_ Date: "04' i� 4, FOR DEPARTMENT-.U,SE ONLY Application Accepted by w 4ADate Area (� Pit or Grout Inspection by, Date .` r-Final Inspection by pate ( db V i Additionaleeomments: r .� f Stk 466-6781 _ ❑ Lodi '369-3621 ! •Manteca;r 8?3-7104 ❑ Tracy 835--6385 Applican ,Jieturn/all copies to: Environmental HealtKPer'mIt/Services 1601 E. Hazeltoonn,,4e., P.O. Box 2009, Stk., CA 95201 ff AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. f a'r I— + EH 13-24(REV.s/RW f76' �� 111dJ �^�`5, ry j�—'3�� EH 14-28 f� ►VI(J w ' J