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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON 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. 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 / 7-Icd 9 S'.J/A/V A11,6/V T'. City � /�D rV Lot Size PM Owner's Name !'1.1L, d&s i?�t,�UAddress S A W? Le Phone Contractor C rJl..�L> pr�� _Address-4003 n')In License No.,2J lCa/l) Phon `2� r TYPE OF WELL/PUMP: NEW WELL L WELL REPLACEMENT L DESTRUCTION ❑ PUMP INSTALLATION F1 SYSTEM REPAIR C OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .- ..._. DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C Industrial r Open Bottom G Manteca Dia. of Well Excavation Dia. of Well Casing XDomestic/Private L Gravel Pack ❑ Tracy Type of Casing I _- Specifications C Public J Other C pelta Depth of Grout Seal # Type of Grout ❑ Irrigation ---Approx. Depth 1. L� Eastern ,Surface Seal Installed by Repair Work Done X Type of Pump �h�— H.P. ._ � _ J State Work Done P4 rhave J 424t,er Iva"7 Well Destruction C Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC.WORK:. NEW INSTALLATION 17 REPAIR/ADDITION C DESTRUCTION ❑ (No septic system permitted if public sewer is J %J .� vi LJ' I available within 200 feet.) S \Installation�will serve: Residence ! Commercial Other { Number of livin %g units: }_ Number of bedrooms - 9 Character of soil to a depth of 3 feet: _ _ Water table depth "5 SEPTIC TANK C Type/Mfg __ Capacity– No. Compartments PKG. TREATMENT PLT. I I~ i F Method of Disposalb r Distance to nearest: ( if Well Foundation I i Property.L-ine r�f i LEACHING LINE J No. & LenBth of lines_!�'Y_ i f Total length/size ' �""` _ P FILTER BED O Distance to naarist: Well Foundation ' Property-L'ine SEEPAGE PITS J Depth _Size Number SUMPS w71^Distance-to.nearest:--Well.— _—_F.oundation iI —Property-Une._. , DISPOSAL PONDS :1t - - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordJnances, state laws, and rules and regulations of the San Joaquin Local Health.District. I Home owner or licensed agint's signature certifies the following:"I certify that In the performance of the work for which this permit is issued, 1 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 ttiat 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 applicalirrVust call for all uired nspections. Complete drawing on reverse side. SignedTitle: _&ICAA9A__ 1 i'"'�~ fl_ Cr FOR DEPARTMENT USE ONLY Application Accepted by �1�✓ Data rea - CR Pit or Grout Inspection by ~ `__'Date f Final Inspection ` "'" �•, Date _"�!(j Additional Comments: C Stk 466-Ml ❑ Lodi 369-3621 C Menteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CIA i FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT Nd. INFO + EH13-24(REV.i r e i 11 —7-7 y EH 14-26 p / ti