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i u n APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` ( " 1601 E. HAZE T ON AVE., STOCKTON, CA (� Telephone (209) 466-6781 SCD : ' PERMIT EXPIRES 7'YEAR FROM DATE ISSUED (Complete in Triphcate) j `�J Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal!the work herein rib hi pplication 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 i Local Health District. C1el- eF daf� Job Address T.;Z Z_ LI Int-i RI City_-.-ke Lot Size PM ± -t Owner's Name M /�/ �i`+/�!/lr VAddress _ t Chi _ _ __/�, � Phone ' Contractor �/>wAJ ' Address_ f= �'�� °�C License No. Phone TYPE OF WELL/PUMP; NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD.�� PROP. LINE FOUNDATION _ 'y"'AGRICULTURE WELL --� OTHER WELL =! PITSlSUMPS � � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing gDomestic/Private ravel Pack LD Tracy Type of Casing __ _ _ Specifications , I'1 Public ❑ Otper F1 Delta Depth of Grout Seal Type of Grout I t Irrigation ��L'Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done L1 Types`of Pump H.P. 0- State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') _ r TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION l 1 DESTRUCTION I I INo septic system permitted if public sewer is l available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line j i LEACHING LINE ❑ No. & Length of lines Total length/size } FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number r SUMPS 11 Distance to nearest: Well FoundationProperty Line10 DISPOSAL PONDS ❑ Ni tl 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 note .employ any person in such manner as to become subject to workman's compensation taws 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." ; I The applicant equired ' ti Complete drawing on rev e side. p 1 Signed X � Title: — Y149w, Date: r FOR DEPARTMENT USE 04Y 7a Application Accepted by - -,> � Date Area Pit or ro t Inspection by Final Inspection by Date l tS{ 0- Date Additional Comments: 0 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Aver P.O. Box 2009, Stk-, CA 45201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASK CK 41 RECEIVED BY DATE PERMIT NO. r EH 13-24(REV.1/n 5) I �� -:x3`4 i EH ��1 1)