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s , f i APPLICATION.FOR PERMIT SAN JOAQU.IN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,.STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, y, .(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 compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rule"s'and Regulations of the San Joaquin Local HealthDistrict. " Job Address ! / $ —f 2 I r`!� wo- z .. J�/� p.^� City f 1 e COl Lot Size X a p / ply , p 9 Owner's Name Q'.h "Address 6© Q q War �ne - - Phone Contractor Larry Q ' �7 4 Address o2 5 �aLicense No. Phone l f 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 ❑ Tracy Type of Casing Specifications LlPublic ClOther ❑ Delta Depth of Grout Sealk Type of Grout r ❑ Irrigation __—Approx. Depth ❑ Eastern Surface Seal Installed b { Repair Work Done ElType of Pump H.P. tate Work Done— Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth l Filler Material (Below 50') (� 1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION EJ DESTRUCTION EJ (No septic system permitted if public sewer is * available within 200 feet.) (i Installation will serve: Residence Commercial Other fJ%J i Number of living units: . Number of bedroom Character of soil to a depth of 3 feet-Ir�D Water table depth o �' SEPTIC TANK ' Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ J Method of Disposal Distance to nearest: Well 1;�Srr �� Foundation [Q! Property Line >P- LEACHING LINE ❑' No. 8i Length of lines Total7i length/size FILTER BED Distance to nearest: Welt ,r, • a ��z � Foundation�._ property Line J SEEPAGE PITS— O Depth f Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property Line - f DISPOSAL PONDS ❑ f 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'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 become subject to workman's compensation laws of California." Contractors 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.` a kThe applicant must call for all required inspections. Complete drawing on reverse side. r.;✓ Signed X if^ K Q 17 Title. WY!e fZ(G � �'^ �'_ O 7 .` a Date: FOR DEPARTMENT USE O LY Application Accepted by DateArea Pit or Grout Inspection by Date Final Inspection by Date i Additional Comments: ❑ Stk 466-6781 - ❑ Lodi 369-3621 „ )<Manteca W-7104 ❑ Tracy 835-6385 � Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 3 FEE AMOUNT DUE AMOUNT REMITTED i INFO -70 / J{ CASH RECEIVED BY DATE PERMITNO. + EH13-24fREV.i/R5! /Q-�'� `N �' •l;f�r D� � "" EH 1426' / Y"1 O �'