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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone.(209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED f (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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. l �o t r• Job Address " ,246, l�s�r""� b�� City Lot Size PM yOwner's Name MLLI- L1r r )r AddressvoOr bX Z-3 t le z 2a'Fc151-3-709 Phone t 1 o� y��- �n � 51376� Contractor a 11 f Address a License N TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT EJDESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 ❑ Domestic/Private Y ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'1 Public 11 Other ❑ Delta Depth of Grout Seal -Type of Grout r I Irrigation Approx. Depth ( I Eastern Surface Seal Installed by (b Repair Work Done ❑ Type of Pump H.P, State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION " REPAIR/ADDITION I I DESTRUCTION I I Wo septic system permitted if public sewer is available within 200 feet.) ! Installation will serve: Residence Commercial Other Number of living units: _/_ Number ofbedrooms F 60 Character of soil to a depth of 3 feet: Water iabte depth �E SEPTIC TANK Type/f> fg dejre k bank Capacity rd- No. Compartments I PKG. TREATMENT PLT. ❑ j�--� j r(� _ Method of Dispos I • Distance to nearest: Well �.s?S� FoundationProperty i ine LEACHING LINE No. & Length of lines _!_ Total length/size 0 C� LCL`` FILTER BED ❑ Distance to nearest: Well 5�2 -+-Foundation Property Line 1 SEEPAGE PITS Depth g3w Size — �3 Number SUMPS ❑ Distance to nearest: Well i CA' L_Foundation Property Line a DISPOSAL PONDS 0 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's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any 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,1 shall employ persons subject to workman's compensa- tion laws of California." The-applicant must all for all required inspections. Complete drawing on reverse,side. 7 } Signed X� �!'_ - Title: 0W seRI -_ Date: ^� FOR DEPARTMENT USE ONLY ` Application Accepted by Date 2 Area I F 7 r it r Grout Inspect) y Dat e�� Final Inspection by 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 955201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO �r � `Q - * EH 13-241REV.r/h5Y r.�' •�� .6O�dU 1�� l V.( { �t� �� j♦;J EH 14-26 4 '