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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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 �11 CIE` ed ` AK-I fl 14-A-Ck 'O 94'e-681ity �� Lot Size d f 6Cf PM to ,;f CT r 1 Owner's Name GvP✓bC► �• � Address 'r �� pA� �� Phone Aff CA . Contractor 2 Atltlress O 6�CJeA 090,-'W_License NoX-IY5 3304 Phone TYPE OF WELL/PUMP: NEW WELL C3--- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 n Public ❑ Other C I Delta Depth of Grout Seal Type of Grout I Il Irrigation Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material l8elow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:'-Residence L*I—Commercial—=^--Other Number of living units: Number of bedrooms 3 Character of soil to a depth of 3 feet: 10%.J"C Water table depth 0 7� SEPTIC TANK 15, Type/Mfg` Capacity �� No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ?0"001f- Foundation/� �r Property Line Z!ee l"' LEACHING LINE No. & Length of lines 3 Total length/size 42� FILTER BED ❑ Distance to nearest: Well h0t' Foundation 4.0'- Property Line SEEPAGE PITS 14- Depth Size S31N Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ __t)r 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. Home owner or licensed agent's signature certifies the following: "l 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 taws 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 applicantRust call f all required inspect ns. Complete drawing on r verse side. Q fir/ 00 Signed X Title: r»L�1t(C'A"'Z Date: U, RTMENT USE ONLY Application Accepted by ._ ■/_Q..t,,. tit n,. Date 4 l Area i 7 Pit or Grout Inspection by a �p X Final Inspection by Date *-/ Additional Comments ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C 5H RECEIVED BY DATE PERMIT'NO, + EH 13-241REV.1i a 5 , ) 1 11'1r00,o� � (�`�c 1 EH 14-26 I.JJ �.+ j