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i N APPLICATION FOR PERMIT I SAN JOAQU1N'LOCAL HEALTH DISTRICT II t 1601 E. HAZEL T ON AVE., STOCKTON, CA !1. Telephone (209) 466-6781 PERMIT EXPIRES 1' EAR FROM 'DATE ISSUED" I� (Comple 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. .• city Lot Size Job Address: . • owner's Name e rezzeC [5d?A%0^rP I - — Address w - ''Phone + 1 ,[ !�-caL Y ddress, 9"�O� ` -= License Nc�,2 .v`t-Phone Contractor � �- - � .A - . —��--- - TYPE OF WELL/PUMP:. i NEW WELL❑ WELL REPLACEMENT ❑ DESTRUCTION C ``P'\ N'�s�UMP INSTALLATION ❑ "N � � SYSTEM REPAIR ❑ OTHER ❑ +^ DISTANCE.TO NEAREST: SEPTtCtTANIC� + _ ��:SEINER LINES DISPOSAL FLD. PROP. LINE ll FOUNDATION AGfiICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDE�USE` TYPE OF WELL PROBLEM ARI A CONSTRUCTION SPECIFICATIONS Q-� Dia.of Well Casing5 3'/ ❑ Industrial h C Open Bottom � ❑ Manteca,•:.:;'•�:Dia. of Well Excavation --� ❑ Domestic/Private El 'Gravel Pack eTracy Type of Casing Specifications ❑ Public tl C Other ❑ De1m Depth of Grout Seal Type of Grout ¢!� ❑ Irrigation!1 —Approx. Depth Eastern Surface Seal Installed by f 7✓ State Work Done. Repair Work;Done [IType of Pump H.P. t f Well Destruction ❑ Well DiameterSealing Material (top 56') i# Depth _ Filler Material (Below 501 — I TYPE OF SEPTIC.WORK: NEW INSTALLATION ❑ REPAIR/ADDITION C DESTRUCTION ❑ INo septic system permitted if public sewer is II available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms t `' r 4 d p �.;. . _ Water table depth Character of soil to a depth of 3 feet:• ; SEPTIC TANK ❑ Type/Mfg � �i•tx�" r~"Capacity No. Compartments ' z , I i PKG.TREATMENT PLT—Q. It F� _^^^^Method of-Disposal ^ 9 0 }� _ ( a .I Distance'to r�eaPest:-^+-SII � �j� FouFidsiaon Property Line� � t,•� I -- �v'�T Totellerf1W1si£eAL '=" LEACHING LINE �a. &Length of lines7-- FILTER F1 LTER BED' ❑I Dis aI nce to nears :Well Foundation Property One ° +� i } { !r i �r SEEPAGE PITS ❑! Depth Size -•Numtier I SUMPS 01 Distance to�ea_re•t:.t Wells Foundation j 4 4/ Property Line j DISPOSAL PONDS ❑ ! Thereby ceriify that I'have prepared this�application and that the work will be done in accordance with San Joaquin county ordinances,state Ia � d- pules and regulations•°af-,the San"Joaquin Local.Health District. \ i Home owned or licensed agent's signature certifies the following:"I certify that in the performance of`the work afor 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 hirJng or!sub cantractingsignature r certifies the following:"I oertify'that in the performance of the work for which this permit is issued;I'stiall�imploY Persons subject to workman's compensa tion taws ofiCalifornia." i f ( t Gr L The applicant must call for all tiir spections. Complete drawing on reverse side. —� q r lJ� Date: Signed X Title: y I 1 FOR DEPARTMENT USE ONLY I I /,14 Date Area Application'Accepted by ` , p Final Inspection by-' Date _ Pit or Grout Inspection byf Additional Comments: ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-638,5 Applicant-`!Return all copies to:Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. BOX 2009, Stk-,CA 95261 . c ^"'•-FEE`AMOUNT DUE AMOUNT,REMITTED CASH RECEIVED BY L`rDATE EPERMITNO. INFO •"�EA-13:24(REV.'i a s: EH 1428 I� .