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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT :p 1601 E, HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' b (Complete in Triplicate) Application is herebymadeto 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 Job Address , 9� N` 1 --1 u A Ci / city Lot Size PM Owner's Name �.C44� --- Address , -9,2%3 Phone Contract ctrtdQ �tT Address Var License Na. 2lfoO Phone 9_ �� (TYPE OF.WELL/PUMP: NEW.WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION El s SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ^SEWER+INES DISPOSAL FLO. PROP. LINE t I I 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 Casings ` ❑ Domestic/ O.Gravel Pack ,,,,,_0._Trac e - y,_.,,, T_ype.of_Casing Specifications {❑ Public j ❑ Other ❑ Delta Depth of Grout Seal Type of Grout . �l ❑ Irrigation --Approx. Depth ❑ Eastern Surface.SealArfstalled by I Repair Work Done ❑ Type of Pump H.P. r State Work DoVL ne l r ,rte.- g a,oor) :Well Destruction ❑ Well Diameter. Sealing Material )top 5 L 3 Depth �- Filler Material (Below 50') .TYPE OFfSEPTIC WORK:\ NEW INSTALLUATION REPAIR'/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ? # Q�-� f,s / 1,vi available within 200 feet.) 1 Installation,will serve: Rest"end ce Commercial Other Number of living mijts Number lfbedriogms - y / Z Character ofrsoil to a depth of 3 feet: Water table depth 'SEPTIC TANK Type/Mfg C Capacity yL}Q _ No. Compartments PKG. TREATMENT PLT. ❑ Y t i Method of D(s osal Distance to nearest: ;VWill—/00 Foundation /Q Property Line _._ E LEACHING LINE I' No. & Length of lines'- klotal length/size Q )(1-2 FILTER BED ❑ Distance to nearest: Well_/ Foundation 3- -. _Property Line i `SEEPAGE PITS U3-rDep h '--�z�4` � �Size` Number `7 SUMPS If ❑ *Distance td nearest:r Well._I�b Foundation/L'..- Property Line_�4` -DISPOSAL PONDS ❑ � � ,+ I hereby certify that I have prepared this application and`thai the work will be done in accordance with San Joaquin county ordinances;state laws, and mules and regulations of the San JoagginnLocal 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 t0'become subject to workman's compensation laws of California."Contractor's 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's compensa- tion-laws of California." f 14 \ The applicant must-call-for all required-inspections. Complete drawing on rev r sjde. J ` f Date:P? /4 dt4, o,S J !Signed B i � � S Title: � X 3 � F.R DEPARTMENT USE ONLY Application AcceptedbT * ¢ Date Area �- Pi or Grout-Inspection-by-i' =' Date :. O. Final Inspection by Date raj t . Additional Comments: I❑ Stk 466-Ml ❑ Lodi 369-3621 1,Manteca 823-7104 ❑ Tracy 835-6385 -,Applicant Return all copies to: Environmental Health,Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 I FEE _ LiNO AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY__ �._ _DATE PERMIT"NO. -{�— ,--�,--,-CASH j + EH 13-24(REV.I/e 5) , EH 14-26 1 v 1 S lk Y