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g I APPLICATION FOR PERMIT SAN JOAQUIN LOCALHEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES-1-YEAR FROM DATE ISSUED' ' (Complete in Triplicate) Application is hereby made totheSan 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 Ryles arid Regulations of the San Joaquin Local Health District. "•W )c -71y Job Address 7/ '7 �� S � S ` r City A Lot Size ` PM r I i p C� �• �d ct_ - Owner's Name �/ ��<= ' B �'I' Reru(7G"� =Addfess'-� � � Phone- ' Contractor- �� Cyz ��` Rddress ' le Y License No. � � (Phone 3 TYPE OF WELL/PUMP: NEW WELL ❑/ WELL REPLACEMENT❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ l DISTANCE TO NEAREST: SEPTIC TANK Z SEWER LINES DISPOSAL FLD. PROP. LfNE l FOUNDATION lr AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 4.0 Open Bottom' El Manteca I Dia - of Well Excavation Dia. of Well Casing a. � � r i ❑ Domestic/Privater,'` ❑ Gravel Pack ElTrac�: �:• j Type of Casing Specifications ElPublic ❑ Other. / 4 ❑ Delta / Depth of Grout Seal Type of Grout r ElIrrigation �4pprox. Depth LlEastern Surface Seal Installed by Repair Work Done ❑ Type of`Pump H.P. State Work Done ' Well Destruction ❑ . Well Diameter. s Sealing Material4top 50') i /0i Depth �Y f '°Filier Matenal.iBelow 5 '1 J TYPE OF SEPTIC WORK: /NEW INSTALLATION-164 REPAIR`/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 1 Installation will serve Residence Commercials Other - ` "1 Number of living Its: _�L__ Number of bedrooms Character of soil to a depth of 3 feet: A Water table depthLA SEPTICITANK Type/Mfg F,4 LCapacity_ No. Compartments + . 'y PKG. TREATMENT PLT. ❑ rti / `� Method of�Disposal Distance to west: Well Foundation Property Line LEACHING LINE '"No.",&Length-of lines �! U� Total length/sizer f , ��r�- FILTER: ❑ istancia to nearest: Well' t ;Foundation Property Line L/n ,eP SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑. I hereby certify-that-1--Kavepreparord-this-application and that, he work will be done in accordance with Sart 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 whichl this-permit is issued, I shall not art employ!any person in such manner as to become subject to workman's oompensation laws of-California."Contractors 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." l I I r r The applicant must call;fp all r red inspections. Complete drawing on reverse side. ` SignedjXSigned] Title: ' , Date: OR DEPARTMENT USE ONLY Applicatlon'.Accepted by. .4 Date / �? Area Q� � Pit or 6rout Inspection by `Date Final Inspection by Date 40 ' Additional Comments: t' ❑ Stk) 466-6 61 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 8355-6385 F i Applicant-'Return all copies io: Environmental Health Permit/Services 1601 iE. Hazelton Ave., P.O:Box 2009, Stk., CA 95201 t FEE" "'"'AMOUNT DUE__ A1hi10UNT RiciVIITTEO "CK —RECEIVED t3Y DATE PERMIT'NO. INFO 'CASH �(� + EH 1324IREV �fe.5) _. . ._.+...sem. EH 14-28