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q f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ! Telephone (209) 466-6781 I_ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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 IXn 4114 w City Lot Size_ _ ._ PM Owner's Name Address Phone 1' Contractor ��/�C�Q,�Address License No.�'.�.5�� Phoney TYPE OF WELL/PUMP: NEW WELL L] WELL REPLACEMENT ❑ DESTRUCTION ❑ } PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE sI FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS,... ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation &6%o Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 171 Public i 1 Other ❑ Delta- Depth of Grout Seal Type of Grout I I Irrigation _..A0prox-;Depth- 4-d-Eastern ti Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 J, Q t r r Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public'sea'ver is -. available within 200 feet.l Installation will serve: Residence"w�Commercial Other t Number of living units: _� Number of bedrooms�� r' i,: Character of.soil to a depth of 3 feet: T -- iDn��t Water table depth i � II SEPTIC TANK ❑ Type/Mfg 41rr.aX 6". 1` Capacity, No. Compartments r I PKG. TREATMENT PLT. ❑ rt--- r Method of Disposal Distance to nearest: Well r Foundation :Property Line 642 LEACHING LINE No. & Length of lines''. Total length/size �T # FILTER BED Ll Distance-to nearest: Well F unda_Ton �''t Property Line SEEPAGE PITS 11 Depth i -_Size Number t SUMPS Distance to nearest: Well'� �Foundatio� n. .7� Property Line C!T r` DISPOSAL PONDS ❑ I hereby certify that i have prepared this application and-that"e work will be do'rie in.-accordance wviiti San Joaquin county ordinances,;state laws, and rules and regulations of the San Jbaquin Local Health'Di'strict. ' Ar Home owner or licensed agent's signature certifies the following: "!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'"i1ensauon 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, ermit is iss6ed,I shall employ persons subject to workman's compensa- tion � Y Pe p f? Y P 1 P ? tion laws of California." I The applicant must call for.#t re u' d inspections. Complete drawing on reverse aside. Signed X " Title:, Date: FOR DEPARTMENT USE ONLY' Application Accepted by �" y Date 6,111A r re Aa _.16 Pit or Grout Ins y i Inspection by Date Final inspection by -Date U/ � a Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 'Tracy 835 6365 Applicant - Return all copies to: Envir6rimental Health Permit/Services 1601 E. Hazelton Ave., P',0. Box 2009, Stk.; CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BYCASH. `.,, _ DATE _ PERMIT'NOi_ _T. _ --« INFO. !, + Erl ii-24 S .t i x 5) : EH 14-28 � } `