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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT �0\43+ � 0�,,1tsJ Y' 1601 E. HAZELTON AVE.,,STOCKTON, CA j Telephone (209) 466-6781 f PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED N%% 4 Ilk (Complete in Triplicate}. ► Ar. �� 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 �Imade 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. lJob Address IQ 1 50'1 ul EBB gl t9GG r t City SP60–KRU) Lot Size TP X-1 5Q PM Owner's Name '(�}M� -CR S E(� L. Address 01l-5a W e–M STZt Phone 1 —17 1?Contractor si� 1' Address License No. Phone_ ,pTYPE OF WELL/PUMP: € NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ G PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ A 11DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE `v FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i� INTENDED USE 'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of.Well Excavation Dia. of Well Casing E] Domestic/Private ED Gravel Pack ❑ Tracy Type of Casing Specifications 1\J ❑ Public ❑lOther EJDelta Depth of Grout Seal Type of Grout i _ ❑ Irrigation r —Approx. Depth D,Eastern -.w_r ' Surface Seal Installed by IiRepair Work Donees ❑ Type of Pump H.P. State Work Done_ ,:Well Destruction ! ❑ Well Diameter Sealing Material (top 501 i Depth Filler Material (Below 501 t :TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is I * ailable within 200 feet.h Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil.to a depth of 3 feet: Water table depth j SEPTIC TANK ❑_ Type/Mfg Capacity No. Compartments '..PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation .Property Line LEACHING LINE ❑ No. & Length of lines Total length/size .FILTER BED ' t ❑ Distance to nearest: Well Foundation Property Line :%EEPAGE PITS FJ Depth Size Number ;SUMPS ❑ Distance to nearest: Well - Foundation 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 ;mules and regulations of the San Joaquin Local Health District.�.. i 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 icertifies 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- ,tron laws of California." !The applicant must call for all re wired inspections. Complete drawing on reverses side. + :ISigned Xhlk� Title: __- ClLut`Cf Date: I- FOR DEPARTMENT USE ONLY (,Application Accepted byDate Area CU I;)" :lPit or Grout Inspection Date Final Inspection b Additional Comments: li❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 E FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ATE PERMIT�`NO.,ry EH GO r O/rl�ryly7 - EH 113-24IREV. 4-26