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• - APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 601 E. HAZET ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES-11 YEAR FROM DATE 1S9U.E6 (Complete in Triplicate) " 1 Applicin ation 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 549 compliance with San Joaquin County Ordinance No. for sewage or No. 1862 for well/pump and the R41es and Regulations of the San Joaquin Local Health District. o d Job Address — .. q • SST ` City A !moo Lot Size 3 30 )�6 LQ PM Owner's Name ` �X E dress _ _ - Phone Contractor :Arc1 fl-rd�.__: TYPE OF WELL/PUMP:` .L-icense-No-� _YS4 4_Phone &-X�'3 7 IN NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC-TANK = --� _ OTHER ❑ EWER-LINES—==- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL. INTENDED USE OTHER WELL- P1TS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial � � in Bottom ❑ Manteca IY Dia. of Well Excavation Dia. of Well Casing f ❑ Domestic/Private ❑ Grelvel Pack ❑ Trac ❑ Public y* Type of Casing ❑ Otlier °❑ Delta� a Specifications ❑ irrigation "f Depth of Grout Sea! �� Type of Grout �pprox. Depth ❑ Eastern ,Surface Seal Installed by Repair Work Done ❑ Type of Pum ; p H'P' State Work pone Well Destruction ❑ Wel! Diameter Sealing Material (top 50') P Depth ""Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW I�INSTALI AT10N ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ !No septic system permitted if f available within 200 feet.) public sewer is 1 Instalfatii5n`will`serve.Residence Comnierciai Other )2 C✓/S E!� D iPtc//.t/f Number of living units: _L_ I�Number-of bedrooms_:__ _3 _ Character of soil to a depth of 3 feet: C� SEPTIC TANK Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity 1(a O 0 No. Compartments 1L tl u t ? Method of Disposal - Distance to nearest: Well_/OL92 Foundation ndationS i — Property Line LEACHING LINE 07 No.''& Lengthiof lines R FILTER BED h , R Total length/size Z,) ❑ Distance to nearest: . Well J Oo ' � 1 . , t �I Foundatian;� , Property Line = SEEPAGE PITS -Depth 6u r r Size -33 'r < SUMPS .�� + Number, Au,QE SAND — b� � . nce to nearest. Weil_ Foundation �� .Pro Property ❑ Dista _ DISPOSAL PONDS - _'❑ �' �r�`f� -. Pe Line S hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,[ nd rules and regulations of the San Joaquin Local Health_District Home owner r 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 subjecrto workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: ,I certify that in the performance of ilia work for which this permit is issued,I shall employ tion laws of California." I� # *� p y persons subject to workman's compense The applicant must call for all required inspections. Co late drawing on reverse sid } y Signed is Title: I J _ Date: r FOR DEPARTMENT USE ONLY Applicatidq Accepted by, IR' Date �,. Area Pit r Gioutlnspection bey i Date v Final Inspection by � Additional Comments. i %•— !w- ❑ Stk 466 6781 ❑=Lodi*369-3627 ❑ Manteca 823-7104 ❑ TracY..-835-6395_ Applicant- Return all copies lot Environmental Health Permit/Services 1601 E. Hazelto A P.O. box 2009, Stk., CA 95201 d FEE' "# INFO AMOUNT DUE AMOUNT REMITTED CK# " _ :0, CASH RECEIVED BY DATE PERNII T, � r Iy r + EH 14-24(REV.1/8 51 s�- EH 1426