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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON AVE., STOCKTON, CA Telephone (209) 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 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. l Job Address Q ��' City `'�� )?PON Lot Size W 10�-H'-IL-5 PM Owner's Name ' 1 Address Phone E18'—YJS Contractor's NameC 1�� License Na. L12-3--4" Phone r 'r .TYPE,.OF.WELL/P-UMP_: _ NEW WELL -- —WELL.REPLACEMENT-O-- DESTRUCTION-El 4 I PUMP INSTALLATION ED{❑ SYSTEM�REPAIR ❑ OTHER OZ � ;�t��J r- � ��•� j y =DISTANCE TO NEAREST:-SEPTIC TANK SEWER'L1NE5 �� DISPOSAL FLS.�� PROP. LINE } i FOUNDATION �B AGRICULTURE WELL . [ • ° OTHER WELL y� PITS/SUMPS , INTENDED USE I TYPE OF WELL PROBLEMIAREA CONSTRUCTION;SPECIF,ICATIONS, 5 j`I`\ k /� '❑ Industrial ❑ Open Bottom ❑ Mantel (Dia. o Well Excavation ~ I %Dia. of Well Casing :� • I `Domestic/Private : T�Gravel Pack ❑ Tracy: Yype qf-Casing �5pecifidatio'ns °❑ Public ❑ OPer ❑ Delta Depth"of Grout SealX Type of Grout ❑ Irrigation ;J t._�Approx. Depth ❑ Eastern —Surface Seal Installed by ' r 1Repeir Work Done ❑ E Typ}e of Pump �H.R, r r State Work Done 1 Well Destruction ❑ j Well Diameter f Sealing,Material (top 501 ~1 i DeptH , Filler Material (Below 501 E OF SEPTIC WORK: NEVV-INSTALLATION ❑ -REPAIR/.ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is i available within 200 feet.] l ` Installation w e: Residence— Commercial_ Other' '. Number of living units: ' Number of bedrooms ! S 1 . t/. I Character of soil to a depth 6f 3 Water table depth SEPTIC TANK O Type/Mfg _ _ ! Capacity No. Compartments ;;kG. TREATMENT PLT�,E] -�— Method of Disposal 9 y Distance to nearest: Well undation Property Line l 4, (LEACHING LINE ❑ No. & Length of lines I length/size FILTER BED ,❑ Distance.to'near�t: l "Well Foundation Line EEPAGE PITS ❑ Depth Size Number + SUMPS -•Distance-to-nearest—Well---------� Foundation Property tine DISPOSAL PONDS ❑ j 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. I Home owner or licensed agent's signature certifies"thePfollowing: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such mannerl.as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of th6 work for which this permit is issued, I shall employ persons subject to workman's compensa- #ion laws of California." yf The applican m t call or all required-inspe ons-Complete drawing on reverse side. I _ X11 Signed X y� sYLc Title: �f�'Y!2-� / mate: I OR DEPARTMENT USE ONLY ( E Application Accepted by doot rl Date Area Pit or•GroutInspection-by �'� '� Date Final Inspection by Date — Additional Comments: 'iNiAt v/ S O Eb Stk 466-6781 ❑ Lodi 3643621 ❑ 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 1 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT N0, INFO CASH ! �s + EH 13.24{REV.14163) 17/2 / —c/ EH 14-76