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..S APPLICATION FOR-PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 2 1601 E. HAZE T ON AVE:, STOCKTON, CA 0, 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 ._. S—3L S, &Ecc> City Lot Size C PM 4 Owner's Name . 7Q124 SQ.P��V,$��1 Address Phone - 1 Contractor's Name AWAWA4L5 y0m:-icense No. 7g�l 9.,-- Phone TYPE OF WELL/PUMP: NEW WELL ji;, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION P9 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE70 NEAREST:-SEPTfC TANK -SEWER LINES —DISPOSAL - -FLD." _A&_0PROP. LINE Q FOUNDATION ' r AGRICULTURE WELL — OTHER WELL . PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom "C] Manteca Dia. of Well Excavation . /7 Dia. of Well Casing WDomestic/Private ;Mravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ OtherWa ❑ Deltas Depth of Grout Seal D Type of Grout ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by A v ' Repair Work Done ❑ Type of PumpSiler H.P. f�Z State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 a Depth Filler Material !Below 50'1 TYPE OF'SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial I f ,_Other s Number of living units: Number of bedrooms I C//71aracter of soil to a depth of 3 feet: Water table depth SEPTiIC TANK ❑ Type/Mfg ` Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ((�� Distance to nearest: Well ' Foundation Property Line V LEACHING LINE ❑ No. & Length of lines ":Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Lar Number SUMPS ❑ Distance to nearest: Well Foundation t '"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 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 must call fo ail required -inspections. Complete drawing on reverse std . Signed Title: Date: FOR'DEPARTMENT USE ONLY Application Accepted by 1 Date r y v / Area ff )Pit or Grout Inspection by - _ ate Final Inspection by. �G-�.�-- flats ' Additional Comments:§ i" O tStk 466-6781 ❑ Lodi '369 3621 -O 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 FEE CK 0 k INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +EH 13-24(REV.1otm) - (J Q •� CVL [J J[�—_Rl QLf,• �L t +,,�