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1 r . `.. 4 APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 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/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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 3245 Wct Cit Lot Size 5 rY1150.1 _ PM s Owner's Name (>JZUban E. Ross Address Phone 943-1799 Contfactor B•CU Rozz COY tAUCtLO40dress 3245 WGitPttlaa RD License No•f 341 375 Phone 7'9- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM RE IR ❑ OTHER CI DISTANCE TO NE �T: SEPTIIC TANK SEWER LINES DISPOSAL FLD. PROP. LINENDATION AGRICU E WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE ELL PROS AREA CONSTRUCTION SPECIFIGATIONS ❑ Industrial Q Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack acy Type of Casing_ asing Specifications �V f`1 Public ❑ Other f7 Delta Depth of Grout Seal Type of Grout I I Irrigation pprox. Depth 12 Eastern Surface Seal Installed by _ Repair Work Done Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Ito 1 V� Depth A Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATI %ia . R/ADDITION IJ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence X Com eOther rNumber of living units: � Number of bedr Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity--6:2-0— No. Compartments PKG. TREATMENT PLT. ❑ C o Method of Disposal Distance to nearest: Well Foundation Property Line LEAGHING'LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property line I� SEEPAGE PITS i I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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."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- tion laws of California." The applicant mu for all re tions. Complete drawing on re erse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by v y Date ` �� dIle- ' 11 Area rp Pit or Grout Inspection by Date Final Inspection by e- [! .[l _eL .f e Date 17 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'NO. INFO l + EH 13-241REV.rin51 '��C '3 ` �, � . EH 14-26 �.7