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f � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. ; Job Address 1714 City Lot Size PM Owner's Name z r"� Address �+ Phone Contractor t! , _Address 120 9)e 119 � 7611 License.No. f _. Phone I TYPE OF WELL/PUMP: - -- NEW WELL ❑ WELL.REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE `x 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 i ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications 17 Public C! Other � Ck Delta Depth of Grout Seal Type of Grout —. I I Irrigation _.App(oxi Depth I I Eastern Surface Seal Installed by ' 0 Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth 1 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION I 1 fNo septic system permitted if-public sewer is available within 200 feet.) Installation will serve: Residence 'Other Number Number of living units: Number of bedrooms �'} 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity 26�00 -- No. Compartments PKG. TREATMENT PLT. ❑ Y Method of Disposal Distance to nearest: Well Foundation Property.Line 4 LEACHING LINE ❑ No. & Length of lines ` Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I � � SEEPAGE PITS 'VI Depth _ ,t� Size Number it � J i SUMPS ; ❑ Distance to nearest: Well Foundation Property Line J 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 fol4 ing: "I certify that in the performance of the work for which thispermit is issued, I shall employ persons subject to workman's compensa- E tion laws of Ga rnia." - The appli nttitfira Iged;'inspections. Complete drawing on re rse side //� Signed X Title: A �• f`Is�'o Date: f OR DEPARTMENT USE ONLY Application c p d byADate Area Pit or Grou Inspection b Final Inspection by Date Additional Comments: --❑ Stk 466-6781 "❑-Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I INFO i AMOUNT DUET +AMOUNT REMITTED C 3H RECEIVED 13Y DATE PERMIT NO. ♦..EH 13-24 1REV.i i H 5S / /._� ✓.� //J// �iJ(/.-LiJ