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APPLICATION .FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. TWs application is• made iri compliance with San Joaquin County Ordinance No.549 for sewage 1r1r No. 1662 for well/pump and the Rules and Regulations of tfie San Joaquin Local Health District. : p /� I _ �/ ..vim-•.^�."� , Job Address / � V/1� y/ �8 _ Cid, Lot Size PM Owner's Name '�'�l�9iYo f7�y i��` Address ��o�U TOSS,� ,AvA Re ?hone /• �'•? G Contractor Z:1 Address f'�' yINX � r ' License No. yy .g� t Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 9+ DESTRUCTION 10 ° PUMP INSTALLATION ElSYSTEM REPAIR El OTHER'1,0 DISTANCE;TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL i PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial r ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing Y C1Domestic/ Private ❑ Gravel Pack F1Tracy Type of Casing I Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal f Type of Grout ❑ Irrigation! ---Approx. Depth ❑ Eastern Surface Seal Installed by Lr { Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material {top 501 - Depth Filler Material {Below 50'1 ~ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted A public sewer is {available within 200 feet.) Installation will serve: Residence L Commercial_ Other Number of living units: I/— Number of bedrooms € Y Character of soil to a depth of 3 feet: ' Water table_depth i. SEPTIC TANK Type/Mfg ° C/D Sr Capacity= 4t40 No. PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: well �� f Foundation '�� Property Line f � � LEACHING LINE No. & Length of lines � "" �� Total length/size res ' FILTER BED i LJDistance to nearest: Well Foundation ¢Q Property Line'F/ oma SEEPAGE PITS ❑ Depth; Size ��r�.�d # Number SUMPS `/ Distance to nearest: � Well a Foundation "�'"�Prb Perty Lihe u DISPOSAL PONDS ❑ 11 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and t rules and regulations of the San Joaquin Local Health District. E r ; 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, 1 shall not r employ any person in such manner as to become subject to workman's compensation laws of California."CiintiactGr's hiring or sub contracting signature i u certifies the following: "I certify that in the performance of the work for which this permit is issued,d shall employ persons subact to workman's compensa- tion laws of California." .I r r I The applicant must II for all re uired inspections. Complete drawing on reverse side. 4 Signed Title: Date: t—, �o ' DEPARTMENT USE ONLY t ; _ Application Accepted'by Date' Area Pit or Grout Inspection by Date Final Inspection by Date —14 .A A. r. Additional Comments:F ❑ Stk 466-6761 ❑ Lodi 36.9-3621 ❑ Manteca 823,7104 ❑ Tracy 835-63!3.5' ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2M, Stk., CA 95201 FEE � " INFO f AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE 4 PERMIT`NO. + EH 13"241REy.1/951 �� ,. EH 14-28 �' ddd-