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APPLICATION FOR PERMIT U U O SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 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 I 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 S�L�1 ril �'1t1taK � City s �� Lot SizeSI�37V ' PM Owner's NameL+ &R" Address 0 • Zde Phone � /+`�� w�r•Address ,`�' •VCV,, 'C License No..ZQ o._ Phone46.3 Contract t. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 C Industrial ❑ Open Bottom ❑ Manteca Dia.of Well Excavation Dia. of Well Casing f� C Domestic/Private U Gravel Pack ❑ Tracy Type Of,Casing Specifications I 17 Public n Other n Delta Depth of Grout Seat Type of Grout__._s_.__ I Irrigation __ApproxTDeplh-1-1-Eastern- -Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ I1 I Well DestructionLlWell Diameter Sealing Material trop 50'I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is Iavailable within 200 feet.) Installation will serve: Residence_ Commercial N/ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation- ..-� Property.Line 1 LEACHING LINE ti/No. 8 Length of lines Total length/size FILTER BED ❑ Distance'to nearest: Well ....._ Foundation—t5,7, Property Line SEEPAGE PITS IF✓Depths Size Number s j SUMPS �"� r Ll;_Distance to nearest: Well 'e& Foundation.0 Pioperty line es DISPOSAL PONDS ❑'�'.'.. r _. /' `. ,\ V 7 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,'slate laws, and rules and regulations of the San JoaquinLocal Health District.fw Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work Rfor which this permit is issued. I shall not employ any person in such manner as to become subject to workman's compensation laws of Calitomre."Contractor'si,hiring or sub-contracting signature certifies the following: certify that in the pe ante of the work for which this permit is issued, I shall employ persons subject'to workman's compensa tion laws of Californ' The applic t m I for all require ctions. mplete drawing on re side. . Sig _ - Title: r —FOR DEPARTMENT USE ONLY +' Application Accepted by 1 _ � ' Date Area i Pit or Grout Inspection by '' Date Final Inspection by Date Additional Comments: - - =- - j 71 Stk 456-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5 l i Applicant- Roturn all copies to: Environmental Health Permit/Services 1601 E. HazeltonlAye., P.O. Box 2009, Stk., CA 85201CK I � FEE AMOUNT DUE f' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. / INFO a.EH 13-24 IREV.r/n5i EH 14-20 7