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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL:HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 112091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED s-v (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. ',4 -. / Job Address I 90 . el�• /7?A e/ Oasx,.- �D City S Lot Size IS.S�X J 7�1 PM Owner's Name /5`/v/ ,JQ ��p,�gss 5,41yJe_� _ Phone _5-in S 5 Contractor's Name GLAD 42 47 License No. /,Z Phone ? .L-S-`39 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 0 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by O Repair Work Done E3Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 rn Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ INo septic system permitted if public sewer is / N. available within 200 feet.) Installation will serve: Residence✓ Commercial_ Other i y� Number of living units:�... Number of bedrooms fif Character of soil to a depth of 3 feet: t" Water table depth ' SEPTIC TANK ❑ Type/Mfg {� Caapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Total length/size �X Z j FILTER BED ❑ Distance to nearest: 1/Vell '�S• Foundation Property Line r' SEEPAGE PITS 9KD,pth ?/S_ ` ' 'Size_g? f r Number, SUMPS ❑ Distance to nearest: y ,Well l Od Foundation � Property Line 2�J DISPOSAL PONDS Cl 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 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."Contractors 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%compensa- tion laws of California." : 1 rj i _ — _,.�-.: , .- The applicant must call for all equired inspe ions. Complete drawing.on reverse side. 1 Signed 6` Title: Date: FOR DEPARTMENT USE ONLYM4 1 � } Application Accepted by i VIA. r TA�,�sx.r.•� Date ` "�� Area © , r GJ".,r Grout Inspection by pection by �. a,,�p..��Date R 1i• ( + Additio'nai Comments: f C ❑ Sfk x'466-6781 ❑ Lodi '369 3621 ❑'Manteca 823-7104 Z11-Tracy-835-15M J �' Applicant- Return all copies to:•Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I _TINFO AMOUNT DUE `AMOUNT REMtTTED CASH RECEIVED BY, DATE PERMIT"NO- y +EH13-24 4REV.10189) rwz EH 14-26 a 1 S k Z