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-W O APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �- - ` 1r 1601 E. HAZELTON AVE.,--STOCKTON, CA ra 'Telephone (209)`466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1� v k. (Complete in Triplicate) lel; Application is hereby made to the San Joacluin Local Health District for a permit to construct and/or install the work herein de crtetl. 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. CNVIRONMENTAL HEALTH r PERMIT/SERVICES Job Address ` Q 1t Y�rnQL - City-5 Lot Size PM `1 33 Owner's Nam �,Kd-__.._ Phone Z e/ � f�� y .I� CSI ' ��7 Contractor Address aoxl q Z.7 License No.JbG�J__3___Phone z TYPE OF WELL/PUMP::, N `. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 'rPUMP INSTALLATION. ,,SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST{- EPTIC TANK: SEWER LINES DISPOSAL FLD. PROP. LINE �J FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA'~'CONSTRUCTION SPECIFICATIONS w ❑ Industrial 1 ❑ Open Bottom �❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack, � ID Tracy Type of Casing Specifications rFlfublic ❑Other l Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation _.-Approx. Depth l I Eastern "'r" Surface Seal installed by Repair Work Dane ❑ Type of Pump P State Work Done Well Destructions 0�. Well Diameter ' Sealing Material Itop 50'1 r `Depth ; Fiiler'Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION {1 REPAIR/ADDITION r'I DESTRUCTION;i I (No septic system permitted if public sewer is available within 200 feet.) �O Installation will serve: Residence_.Commercial_ O her Number of living units: Number of bedrooms �° C Character of soil to a depth of 3 feet: Water table depth - SEPTIC TANK- I. '❑ Type/Mfg t °w Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well - Foundation Property Line LEACHING LINE ❑ No. & Length of lines '' Total length/size FILTER BED'r ' ❑ Distance tri nearest: Well �^ Foundation Property Line SEEPAGE PITS J l I f Depth Size f- Number SUMPS - y ; -Ll Distance to nearest: Well , �4oundation Property Line DISPOSAL PONDS ❑ I r 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. Home owner or lic agent's'signature.'certifke the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any on in such nner as to become sU ct to Workman's compensation laws of California." Contractor's hiring or sub-contracting signature I certifies t to "I c ify that in t r n of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion law of California." I The ap icant mu f all re plate drawing on re r ide. M Q� 1 Signal Title: � Date: i FOR DEPARTMENT USE ONLY 1 Application Accepted by Date Area Pit or Grout Inspection by Date,- o Final Inspection by �? Dat4 &V-q4 Additional.Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑\Tracy 835-6395 h i<. Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.;,P.O. Box 2009,` Stk., CA 95201 1 i FEE AMOUNT DUE AMOUNT REMITTED CK 0 / CASH RECEIVED BY DATE PERM17'gqNO. + EH13-241REV.t/x51 .�(� �`, —i-Ip [0^I7d�g EH 14-28 I i