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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone Q091 466-6781 PERMIT EXPIRES 7 YEAR 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. �' f Job Address , ! �- f `-' �,f f�r f � City Lot Size 4glk PM y r is Owner's Name� ��Q2219JAddress �[T z a� f f7y '� Y_,.JR Ph;ne C9 Contractor "Y) 7e Address 5'�`?] License NoA 9'6'90 Phone " TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ U0 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _.Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is i available within 200 feet.! Installation will serve: Residence_ %._ommercial Other ` Number of living units: Number of bedrooms_ Character of soil to a depth of 3 feet:1 i ''r ' t z Water table depth ' SEPTIC TANK ❑ Type/Mfg Capacity 2 Cl No. Compartments PKG. TREATMENT PLT. ❑ r C Method of Disposal Distance to nearest: Well`�U Foundation !O Property Line r '+ LEACHING LINE No_ & Length of lines Total length/size 't FILTER BED Distance to nearest: Well� Foundation YO 7__ Property Line .-_�_(L__ .61 SEEPAGE PITS ❑ Depth Size Number 11 e SUMPS ❑ Distance to nearest: Well Foundationow Property Li DISPOSAL PONDS ❑ I 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. If W I � 14 , r Home owner or licensed agent's signature certifies the following: "I certify!hl in the performance of,the work for which this per it is issued, I'shall not'\ employ an person in such manner as to become subject to workman's compensation` } - e" s _ P Y Y P i laws of California. Contr`actor's hi`ing or'su -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 woikrfiSA's compensa- tion laws of California." xy I ; 4 , I I { The applicant st call for ail ired i ctions. Complete drawing on reverse side. .. i a Signed Title: 'y '1 �P V- Date: �i< "2 FOR DEPARTMENT USE ONLY Application Accepted by Dategfea Pit or Grout Inspection Date Final Inspection by —-Date Additional Comments: ❑ Stk 4664781 \ P ❑ Lodi 369-3621 ❑ Manteca 823-7104 '` ❑ Tracy 835-6385 ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazslton Ave.,tP.O..IIBox-X009, Stk., CA 95201 +; ... -e—s FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED i31�,C t ,DATE PERMIT NO. + EH 1324(REV.1iR5) •/U 7 EH 14-26 / ,� _ E `- X-�L—tf / �/�!