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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYtEAR 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 20695 LIBERTY RD. CityµC.T•EMENTS Lot Size d PM Owner's Name JERI S. UBST Address Phone — 375-1 Contractor L. WAYNE BECK 8102 KELLEY D License No. /x$91$4_..,____Phone_ 476-0425 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION❑ SYSTEM REPAIR ❑ OTHER ❑ 0lSTANC NEAREST: SEPTIC TANK '7� SEWER LINES -- DISPOSAL FLD. PROP. LINE FOUNDATION ju__ AGRICULTU L OTHER WELL PITS/SUMPS INTENDED USE PE OF WELL PROBL EA CONSTRUCTION SPECIFICATIONS �. ❑ Industrial ❑ Open ttom anteca Dia. of Well Excavation Dia. of Well Casing 1 n Domestic/Private ❑ Gravel Pa ❑ Tracy Type of Casing Specifications P Public ❑ 0511#1. elta Depth of Grout Seal Type of Grout I I Irrigation _A G F�. Det_nfh I 1 Easter Surface Seal Installed by Repair Work Do ❑ Type of Pump H.P. State Work Done T Well Des ion ❑ Well Diameter Sealing Material Ito Depth Filler Material (Below 501 YPE OF SEPTIC WORK: NEW INSTAL; TI REPAIR/ADDITION DESTRUCTION I 1 (No septic system permitted if public sewer is ` available within 200 feet.) INInstallation will serve: Residence k— Comm rcial Other Number of living units: J_ Number f becjroo s �7� - t Character of soil to a depth of 3 feet: A_ 6-1 Water table depth SEPTIC TANK ❑ Typ.,&!g , Capacity No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to nearest: Well 7- Foundation Property Line ©a f IF LEACHING LINE �o. & Length of lines g�L1 �� Tptal length/size ---- FILTER BED D Distance to nearest: Well i/e _ Foundation Property Line 6?0 SEEPAGE PITS i r Depth �Z � Size Number SUMPS L-i Distance to nearest: Well Foundation Q Property Line — DISPOSAL PONDS ❑ 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: "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 glupt call for all required inspections. Complete drawing o revers �)� Signed X Title: Date: (fl�l FOR DEPARTMENT USE ONLY f� Application Accepted by I / Date i Arealei Pit or Grout Inspection byate inal Inspection by 1 �.-� Date �� Additional Comments: `u Y �r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca fa23-7104 0 Tracy 835-6385 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 C SH RECEIVED BY DATE PERMIT'NO. INFO �j + EH 13-24 iREV.I/n 51 9D 70 4 COQ EH