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. 4�t APPLICATION FOR'PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT `1Urd f 141AII ,1 I 1601 E. HAZELTON AVE., STOCKTON, CA �.4N JOAQUiN Q1ST �- n 1 Telephone (209) 466-6781 HEALTH DI -T R(� 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. i i Job Address 3 buy.-00 City LS04LDLot Size_ PM Owner's Name Address Y-)-, L Phone Contractor's Name�� -7 J*Aj � Ucense No �0 Phone () TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ T PUMP INSTALLATION ❑ SYSTEM REPAIR )C OTHER ❑ w DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE F,QUNDATION 1, ' AGRICULTURE WELL _''—,OTHER WELL' - ` PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing r Specifications Vf Domestic/Private E] Gravel Pack' ❑ Tracy p Type of Casing P� ❑ Public ❑,Other ❑ Delta Depth of Grout Seal Type of Grout C Irrigation _-�pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 'A Type of Pump Sig '.H.P. State Work Done — u Well Dastructlon C Well Diameter Sealing Material (top 501 Depth filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION C DESTRUCTION ❑ INo-septic sy§tem Permitted.if,public sewer is available within,200 feet.) Installation will serve: Residence Commercial I Other r +� Wumber. of,living units:_ Y Number of bedrooms Character of soil to a,depih of 3 feet 's-tea, Y Water table depth SEPTICf TANK \ al r n—Type/Mfg,I Capacity No. Compartments I PKG. TREATMENT PLT.❑ Method of Disposal ' Distance to nearest: Well Foundation Property Line W t ;t 1` ( LEACHING LINE ❑ No. & Length of lines ' ! Total length/size t "� 4 FILTER BED ❑ Distance to nearest: Well t Foundation Property Line. ' SEEPAGE PITS 7 Depth Size Number — SUMPS ❑ Distance to nearest: Well1___ Foundation Property Line DISPOSAL PONDS ❑ I 1 4 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 oertifies 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 subieot to workman's compensation laws of California."Contractors 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 app ust II for all eq ire spectIons. Complete drawing on reverse side. g Si ned Title: .. . Date: O FOR DEPARTMENT USE ONLY �� AApplication Accepted byvDate �'2" LA Pit or Grout Inspection by Date Final Inspection byDate ✓� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6.386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I � ' FEE I INFO AMOUNT DUE 7 AMOUNT REMITTED CASH RECEIVED BY /DATE PERMIT"NO. [ t ER13-241PEV.70/63) 111. EH 14-26