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APPLICATION'FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE l ON AVE., STOCKTON, CA .Telephone 1209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM,DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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. AC. Job Address /��yy P/y919-S F city. �9 G Lot Size ` PM Owner's !Name ��=�iGC CS�.t trs%v l�L� Address Phone Contractor41_,J�ZAddress U �TLicense No. c�_��T7,�Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT_-❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM'REPAIR ❑ _ OTHER ❑ DISTANCE TO NEAR S�EPPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNUe� AGRICULTURE WELL OTHER WELL PITS/SUMPS t I INTENDED USE'"- "--TYPE`OF WELL M AREA`"-'CONN' RUdFIC-MSPttiFICATIOWp-..rs Industrial ❑ Open Bottom ❑ Manteca t. .�" ia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Tracy "� !s :1 Type �sing Specifications } p Public ❑ Other { �.' ',..Q Delta` ti:, Depth cif Grow 5e I Type of Grout 0 Irrigation �4pprox.�Depth; El Eastern "'u,Surface`Seal Installed Repair Work Done ❑ Type of Pump H.P.._ State Work Done :..'... Well Destruction E-) WellDiameter •'Sealing Materials{fop-50'1 + s Depth " Filler Material (Below 50) TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ` i �A available within 200 feet.) - Installation will serve_,, -Residence-4t— Commercial Other Number of living nits:__L_ Number of bedrooms .. ' ;Character of soil to a depth of 3 feet: A D Water table depth # SEPTIC TANK ❑ Type/Mfg CapacityL_—No. Compartments { PKG. TREATMENT PLT. El Method of Disposal I `'A -Well E ~'Foundation �;r' � � �'� Property Line!...-- l Distance to nearest w ' DtJ. Total len th/size LEACHING LINE No. & Length ofrlines '� 9 FILTER BED '❑ Distance to nearest: Well Foundation 02 F Property tine t i p -r- i SEEPAGE PITS ��0"""De th` Size� _ Number � • SUMPSli)7"'Distance to nearest.' Well Foundation Property Line. DISPOSAL PONDS F-1 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: lI '"'_,. -.� I . , Home owner or licensed agent's signature certifies the fallowing: "I certify that in khe:performance of the-work for.which.this.permit-sAssued, I shall not employ any:person;in such manner as to become'subject to workman's oompensation laws of Cal-ifornia."•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 mus call fo all req fired inspections. Complete drawing,on-reverse side.. ---,�, _ ` 5jgned - Title: - � Date: _ I i i { FOR DEPARTMENT SE ONLY Date / Area Application Accepted by /J PNor Grout Inspection by Date Final Inspection by Date r Additional Comments: ` C3Stk 466-6781 ElLodi 369-3621 ❑ Manteca 823-7104;,. :..., .Q Tracy A 8354M r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E,Hazelton Ave., P.O. Box 2009, Stk., CA 95201. 1 FEE 'AMOUNT•DUE - AMOUNT REMITTED -CASH RECEIVED BY DATE PERMIT"N0. } t � INFO +EH 13.24 v EH 14-20 - - _