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h r I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.; STOCKTON, CA Telephone (209);466-6781 PERMIT EXPIRES 1 YEAR I ROM DATE ISSUED t (Complete in T11 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` t �y (n� r � Job Address �' 11 City. ``�W ! Lat Size X 3t-pM` t Owner's Name _k13ACLE ��G[ I R,� Address Phone L , r Contractor L Address - ""r O�License Na. Phone �` �a�- ». ---- — TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 PUMP INSTALLATION ❑ SYSTEMI REPAIR ❑ - OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL( OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL� PROBLEM AREA�'y`CpNSTRUCTION SPESPECIFICATIONS"" """""�'�'" ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack EU Tracy Type of Casing Specifications t E Public C1 Other `.� {1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation .� n -�,-Approx�Depth i I Eastern Surface Seal Installed by Repair Work Done , ❑ Type of Pump' H.P. State Work Done Well Destruction- ❑ "Well Diameters Seating Material stop 501 + Depth " _ Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within.200 feet.) s Installation_will serve: Residence C mmercial_ ther i Number of living units: Number of bedrooms >' Character of soil to a depth of 3 feet:1- 6j— Icv�n Water table depth 'SEPTIC TANK 1� Type/Mfg -�� Capacity No. Compartments PKG. TREATMENT PLT. ❑ I f. Method of Disposal i r Distance toynearest: Well 1CO Foundation •Property Line LEACHING LINE L4—!'+fts&Length of lines �� "k Tatallength/size FILTER BED ❑ Distance to'nearest: Well "Foundation 2k, Property Line r -� SEEPAGE PITS t4-�eptti' Size Number { k. SUMPS --^ •--rLL or Distance-to nearest: Well Foundation Property Line DISPOSAL PONDS k O I f 75 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. Nome owner or licensed agent's signature certifies the following: "I certify that in�lthe performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subiect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature ice U' s the following: "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 zi it nia." {� i The applican m all fo}all re s. plate awing on erse'Isi Sign Title: Date: � FOR DEPARTMENT USE ONLY , ! Application Accepted by jI Date { qALM I; _ rea Pit or Grout Inspection by Date i Final Inspection by +Date Additional Comments: t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 " ❑ Yfacy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED a CK RECEIVED BY DATE PERMIT NO. INFO CASH +.EH13.24MEV.I/H51 �� !` EH 14-28