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' M APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT (�:� 1q AJ 1601 E. HAZEL I ON AVE.-, STOCKTON, CA ~�� 2 Telephone (209) 466-6781 X N 6 7 8 / 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 f 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. ,, r Job Address CT/ d A) fJ City S Lot Size PM a 11 Owner's Name r, ` _�et7,S Address ✓ T! d Phone Contractor kX�zyl#f dr 4tz Address 14 Z 13'1 W J-T d7 License No. Phone 'TWF WELL/PUMP: II NEIN WELL ❑ WELL REPLACEMENT-❑ DESTRUCTIONS%s PUMP INSTALLATION ❑• SYSTEM REPAIR ❑ OTHER EJ ' DISTANCE TO NEARES r IC TANK ` SEINER LINES DISPOSAL FLD. PROP. LINE 'o FOUNDA AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR AREA' CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca k' . of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack �-p.Tracy- Type of Specifications t-� ❑ Public Cl 11. 11 Delta x Depth of Grout Seal Type of Grout y ❑ Irrigation _11Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Q Type of Pump H.P. %� 3+' State Work Done -� Well Destruction O Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION © DESTRUCTIO (No septic system permitted if public sewer is vailable within 200 feet.l Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth .y: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 11: Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ,i. FILTER BED ❑ Distance to nearest: Well Foundation Property Line I' ,. SEEPAGE PITS ❑ Depth Size Number :F. SUMPS ❑ Distance to nearest: Well Foundation 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 Sdn Joaquin Local-Health-Oistricf: -•--- - °°*""'"" ` "*"""""""'s "'"""^ ' �"" 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 Califomia."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 t call for allI'req • •nspe ions. Complete,drawing on reverse:side. Signed Title: Dater ai FOR IDEPPAlITMENT.USE ONLY Application Accepted by Date - �A� -- Area WA * 1. - ,� -- sok^ —, . ;Z e Pit or Grout Inspection by I� Date Final Inspection byDate / Additional Comments:- ,0 omments:,❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Cl Tracy 8355-6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH14-24 IAEv-t/s 51 � 3 �S 7 5� EH 1426