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too P► !� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED {Complete in Triplicate}" i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TNs application is d 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, Job Address 3� 6015 A 114– 3 `� ` City S7�Cd Lot Size S X /SO PM Owner's Name Address .34Z� W- -r S.: Phone Contractor C�J/D A5- Laos,D Address G�® G License No. Phone-94,C_–_351w TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Gravel Pack j❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation s,Approxi Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter {' `ti Sealing Material Stop 501 t� Depth Filler Material (Below 501 v TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is t available within 20D feet.} /,41.1 Installation will serve: Residence_ Commercial Other Number of living units: —I— Number of bedrooms Character of soil-to a depth 3 feet: Water table depth SEPTIC TANK Its Type/Mfg Capacity i 7–,Wa No. Compartments 2� PKG. TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: Well Foundation_ 1 Property Line !S r LEACHING LINE 0--ho. & Length of lines f 3ry Total length/sized X ` FILTER BED ❑ Distance to nearest: Well VIA� Foundation f Property Line S' SEEPAGE PITS ❑ Depth "'y ", Size / X g" Number ` y SUMPS Distance to nearest: Well_i4f� Foundation X0 - •Property Line �� 1 DISPOSAL PONDS ❑ 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 4 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, I shall not employ any,person in such manner as to becorne 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- ;t,Ion laws_of California:" - k Tliwapplicant must call for all required inspect's. Complete drawing on reverse side. � Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by ! Date :L, o Area O C3 s tion by Date 401 P final Inspection by ( .. a,.n, Date $b �� ❑ 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 I FEE INFO. AMOUNT DUE_ AMOUNT RE CASH RECEIVED BY DATE PERMIT"NO. + EH 13-241REV.1/651 ' EH 14-26 i � I