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APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL T ON AVE., STOCKTON, CA `� ~ Telephone (209) 466-6781 ,^)nn h PERMIT EXPIRES 1-YEAR FROM DATE ISSUED C (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 Gounty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District" O yy� r� Job Address /' l 144 �f Cit f ' /� -"- -- Y Lot Size PM Owner's Name K-e 11x1 ddress � — Phone r Contractor �L ,� Address 2Z70Z YV \ r,4!) _License Na.6WO" Phone 7*1 TYPE OF WELL/?UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. S ER LINES D AL FLD. PROP. LINE FOUNDATION - AGRI ULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE CON UCTION SPECIFICATIONS El Industrial ❑ Open Bottom Ll Manteca ra. of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack ❑ Tracy T e of Casing_ Specifications M Public n Other F a dept of GPout-Seal Type of Grout _ I I Irrigation —_Approx Depth I Eastern ,Surface eal Installed by Repair Work Done ❑ Type of Pump}�' H.P. , - State Work bone Well Destruction ❑ Well Diameter Sealing Material stop 501 Depth 11 I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION I I DESTRUCTION (Noseptic system permitted if public sewer is �J available within 200 feet.) Installation will serve: Residence t..'Commer6al_ Other Number of living units: i v a Number of bedrooms Character of sail to a depth of 3 feet: I., Water table depth SEPTIC TANK ❑ Type/Mfg -Capacity- 0N . Compartments PKG. TREATMENT PLT. ❑ e Method of Disposal Distance to nearest: ... '"V476I1;'`�� -` Foundation Property-Line LEACHING LINE ❑ No. & Length of lines y Total length/size FILTER BED ❑ Distance to nearest: Well " s-''`' Foundation Property Lihe G SEEPAGE PITS C I DepthI Size J + Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in they/orre of the work for which this ermit is issued, I shall em totion laws of California." P P Y Persons subject to workman's campensa- The applicant must call for all fired iomplete drawing on reverse side. Signed X Title: _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout inspection by Date Final Inspection by Date Additional Comments: �YY1 ❑ Stk 466-6781 0 Lodi 369-36211 0 Manteca 823-7104 171 Tracy. 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE AMOUNT DUE AM NT REMITTED INFO AS RECEIV DBY DATE PERMIT'NO. I EH 14-2013-24/REV,v/x51 Er�f rj