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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'l YEAR'FROM -DATE ISSUED ' +' 44 (Complete in Triplicate) .. - �..- fi 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 Ryles and Regulations of the San Joaquin Local Health District. �: i• �x` c" ti"- + Job AddressCity` "s'" Lot Size :2-5 Cy PM"" Owner's Name r SAA Address Phone A- I�' 351 �' Rd5 a Contractor �� dress icense No. Phone TYPE,OF•WELL-/PUMP:—'s'"j—NEW WELL-1f-------WEL'REPL:ACEMENT-0 ^'^ ""DESTRl1CTION ❑"`-''�"' ��'� - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ s DISTANCE TO NEAREST: SEPTIC TANK SEWER L:-INES -tom DISPOSAL FLA. PROP. LINE L 3 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —1NTENDED..USE—TYPE-OF_WELL�P_ROBLEM-AREA„-__CONST.RUCT-ION-SP.ECIFICAT.IONS-. ❑ Industrial ❑ Opeh Bottom ❑ Manteca Dia. of Well Excavation' Dia, of Well Casing ❑ Domestic/Private ❑F Gravel Pack ❑ Tracy Type of Casing L 4 t Specifications ❑ Public ` Y`J O Other ❑ Delta Depth of Grout Sealr t ”" """;Type of Grout ❑ Irrigation R ----Approx. Depth ❑ Eastern Surface Seal Installed by t ? Repair Work Done ❑ Type of Pump H.P. State Work}Done Well Destruction ❑ Well Diameter- .....__..__., —Sealing Material {top-50'I t, Depth iFiller Material`(Below 50,).- - -- -- —f TYPE OF SEPTIC WORK: NEW'INSTALLATION ID REPAIR/ADDITION UCTION ❑ (No septic system permitted if public sewer is V� r available within 200 feet.) Installation will serve: Redance-�-�Comr nercial_ Other + Number of living units: }Number of bedrooms Character of soil to a depth of 3 feet: _ ) + Water table depth SEPTIC TANK ❑ Type/Mfg �1Ctr.f�t-F- Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ i }- - I Method of Disposal ,I Distance to nearest: Well Foundation Property Line . y LEACHING LINE ❑ !No.{&--Length-of-lines Total length/size FILTER BED est ripe to nearest Well -S70 Foundations Property Line SEEPAGE PITS ❑ ! Depth Size 3 _Number SUMPS ❑ Distance to nearest: Well Foundation_Z!< Property Line DISPOSAL PONDS ❑,�f I I hereby certify that 1 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_SanFJosquin 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 j employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature bll%k the following: "I certify that in the performance of the work for which this pdrmit-is issued, I shall employ persons subject to workman's compensa- tion sof California," The applica u call for I regwr d it tion o ete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area O 4? f� r Pit or Grout Inspection by l Date Final Inspection by Dates ---44-- Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K MH RECEIVED BY DATE PERMlT`NO. 4 + FH 13-24(REV.f/s 5) 11,, 4*11 EH 1426., - .. - S .v " //