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APPLICATION FOR PERMITS ti SAN JOAQUIN LOCAL HEALTH DISTRICT �A 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and lor install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump.and the Rules and Regulations of the San Joaquin Local Health District, r F City M Lot Size PM Job Address 17851 S. Ideal Parkwa { JOSO�h Ki nom. _ Address _ 1 1 2 4 E�c�7 ,• T "^o Man t=P r�a _ Phone Owner's Name r Address 3924 Star_ lite Dr. License No. 231047 Phone Contractor Modern Steel _ WELL ❑ WELL REPLAC DESTRUCTION LJ TYPE OF WELLIPUMP: tOTHER C1PUMP INSTALLATION L) SYSTE REPAIR El { € a DISPOSAL FLD. PROP. LINE �[ Y DISTANCE TO NEAREST; SEPTIC TANK 5E LINES .' AGRIC TORE ELL OTHER WELL PITSISUMPS li �� I FOUNDATION C� INTENDED USE TYPE OF WELL PROBLEM AREA - ONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ industrial C1 Open Bottom ❑ Manteca ia. of-Well Excavation r .... --- : Specifications _ if - T of Casing '� ❑ Domestic/Private Ll Gravel P k b Trac y Type of Grout k f 1 Public f 1 Other ❑ Delta` Dept f Grout Seal I l Irrigation _Approx. Depth 4 I Easter !Surface al Installed by H P : State Work Done Repair Work Done Q Type of Pump` y} Well Destruction ❑ Well Diameter Sealing Material )top 50'I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION ( aNailab lec s stem witin 200 feet.) if public sewer is r � Installation will serve: Residence Commercial_ Other i Number of living units: Number of bedrooms Sandy Lown Water table depth Character of soil to a depth of 3 feet: n Capacity Na. Compartments \ i SEPTIC TANK IX Type/Mfg y�P y /M.✓` Method of Disposal PKG. TREATMENT PLT. 11W Well —j. 21 —Q" NA Foundatio ��r Property Line , - {@ Distance to nearest: : re Total length/size LEACHING LINE LX No. & Length of-lines 2 — 7C t Property Line ❑ Distance to nearest: Well Foundation FILTER BED �. .. ti Size Q ' X 1 [ X 1 Q Number ' SEEPAGE PITS i 1 Depth ' ? r SUMPS [g; '+ f Property Line 7 Distance to nearest: ''� Well _]�A Foundation�� Pe DISPOSAL PONDS LD I hereby certify that I have prepared this application dnd that the work will be done in accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaquin Local Health Di%trict. Hama 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 parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature F certifies the f (lowing:"I certif th t in the pert ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of lifornia." t The applica t1must call for I qu ed spections. m late drawing on reverse side. Y 1 a" Title: Date:" Sr ed X � J R DEPARTMENT USE ONLY y� Data A'® Area Application Accepted by / • = """� Pit or Grout Inspection by Date f� ate Final Inspection by k � }I' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant Return all copies to: Environmental Health ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r• , FEE CK RECEIVED BY GATE PERMIT"NO. @ INFO AMOUNT DUE �yA/IjMOU(NT/JREMI'TTED C(7�AS�H +.EH 13-24(REV.t/rs sl �a r (r')'� ! "1/ a`// EH M-28 v