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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE„ STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED I, (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 - �- I' City � Lot Size JL GY e-1--eS PM 6 v"rTOwner's Name Address � . Contractor ! r ' Address__ _fes, D ZL (!�A" -Licertse No. 4�.'3 R 3 Phone 3 z,-t- r TYPE OF WELL/PUMP: NEW WELL >�, WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMPINSTALLATION-. ---�- .-'SYSTEM-REPAIR.L0.- OTHER,.El t _ , Y -DISTANCERTO NEAREST:-SEPTIC TANK 14 O SEWER LINES DISPOSAL FLD.a- 4 PROP. LINE e FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSI� INTENDED USE V IS, TYPE OF WELL s. PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,1 ❑ I tdustrial '' 'Open Bottom A�❑ Manteca Dia. of Well Excava�tio+n Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracey ' :;F Type of Casing Y 1P��h Specifications �7_ `v f`l Public ^� C� Other ""'� + ❑ Delta Depth of Grout Seal � Type 01 Grout a;e;ue '_ I I krigaiion v-W_Approx. Depth I Eastern S dace Seal Installed by s Repair Work Done ❑ Type of Pump., �tH.P. L" .Z State Work Done Well Destruction ❑ Well Diameter *. Sealing Material trop-E�6'), Depth r4 Filler Material (Below 50'1 ` TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION-{ 1 DESTRUCTION I I (No septic system permitted if public sewer is Favailable within 200 feet.) Installation will serve: Residence— Commercial_ -'Other"' Number of living units: Number of bedrooms' l Character of soil to a depth of 3 feet: \ Water table depth c SEPTIC=TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS I I Depth Size Number SUMPS'A L] Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the wotk 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."Contractors hiring or sub-contracting signature, certifies the-following::.)-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." The'applicant mus call for all required 'nspections,_Complete drawing on reverse side. ' Sigi A X All .AJ_X1 Title: ..!Sr_- e_ A --C�`' Date: -� 9 FOk27ARTMENT USE ONLY Application Accepted by AAAAY�& % «n__��. Date 3-31J6 1 Area Q Pit or Grout Inspection.by �L Date Final Inspection by fv' Date 4 ' �- L-fi Additional Comments: w""ph -�' =Lc�ec - 4 - -.-� ❑ Stk 466-6781 ❑ Lodii369-3621- ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Pgrmit/Services 1601 E. Hazelton Ave., P.O:-Box 2009, Stk., CA 95201 INFO AMOUNT DUE CK 4 FEEl AMOUNT REMITTED ` CASH RECEIVED BY DATES PERMIT NO. +.EH 13-24 Iq EV,I/nsl 1 EH 14-28 6,