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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 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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. Jab Address �/ , G S '` City w• Lot Size �G PM Owner's Name STV S.dU i j29 4r Address s�/�+ Phane333' Z Contractor 1 ' Address#0V � License No3?73 11Y�T PhoneZ3 TYPE OF WELL/PUMP: NEW WELLA WELL REPLACEMENT ❑ DESTRUCTION ❑ ! PUMP INSTALLATION] SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Lop 4 FOUNDATION %� AGRICULTURE WELL OTHER WELL PITS/SUMPS i. INTENDED USE TYPE OF)YELL PROBLEM AREA CO SN TRUCTION SPECIFICATIONS, 1 F1Industrial-.--.___y _❑.Open.Botto'rn_--D-Manteca-- T---.Dia.-of-Well_Excavation Z Dia. of Weil Casing t �WDornestic/Private I Gravel Pack ❑ Tracy Type of Casing/?A,-C - Specifications j F] Public F1 Other Cl Delta Depth of Grout Seal s0 Type,of Grout _ I ] trrigation4 _-Approx. Depth l I Eastern Surface Seal Installed by C.d/y'JX/< Repair Work Done ❑ Type of Pump suO H.P. State Work Done_ i 1 Well Destruction ❑ Well Diameter Sealing Material (top 501 t — Depth Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION.I;I REPAIR/ADDITION t 1 DESTRUCTION I I (No septic system permitted if public sewer is " available within 200 feet.I t i Installation will serve: Residence_ Commercial_ Other € (� Number of-living-units: .-Ndmber-of-bedrooms .y Charracter of soil to a depth of 3 feet: Water table depth SEPTIC TANK .r--9—Type/,Mfg Capacity No. Compartments ' F ' ! ip PKG. TREATMENT PLT. ❑ � Method,61 Disposal � f Distance to nearest: Well Foundation Property Line, j LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED i ❑ Distance to nearest: Well Foundation Property Cine SEEPAGE PITS 1 1 Depths Size Number SUMPSDistance to nearest: Well -Foundation Property Line DISPOSAL PONDS ❑ hf 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 r rules 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 certifies the fallowing: ',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 must all for all required inspections. Complete drawing on reverse 4side._ ` Signed 'Title: Date: S�Z6'a J FOR DEPARTMENT USE ONLY Applicati Accepted by Date Area Pit or Gro t Inspection by Data Final Inspection by Dat r �� Additronel Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE t 4 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. p _ +.EH 13-241REV.i/B5l }� Q S. Do �� U ..L�� •lV"'a l Oq- EN 14-26 1