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APPLICATION FOR PERMIT i 3 SAN JOAQUI'N LOCAL HEALTH DISTRICT- 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. 1. Job Address ®/ C /<Aeit/GY L s�R/G City Ap z)7 Lot Size �-66x 3 PM Owner's Name Address SASE Phone X34- Sao h Contractor, fi E_ l�DD1? Address_`7 �� •'9�Eti� .�T ' E License No, �y�Y7� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS-� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS—.- El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of-Casing Specifications FI Public 171 Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation —_..Approx.Depth I I Eastern Surface Seal Installed by Repair.Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501'. Depth Filler Material (Below-50T TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION X DESTRUCTION I I-iNo_septic..system_permitted.if-public-sewer is Q available within 200 feet.) Installation will serve: Residencey Commercial_ Other \ Number of living units: —I— Number of bedrooms 3 Character of soil to a depth of 3 feet, �S lI'iU,� Y 79 is t ^� Water table depth k SEPTIC TANK ❑ Type/Mfg Capacity &-4-0 No. Compartments Z i PKG. TREATMENT PLT. ❑ -fMethod of Dispo,al Distance to nearest: Well Foundation. 2-7 Property Line si�q LEACHING`LINE' No. &.Length of lines 2— �� f Total length/size d o FILTER BED ❑ Distance to nearest: Welt Dy`' Foundation 30 Property Cine SEEPAGE PITS k+F Depth lD Size rr ��'JZ _ Number. SUMPS , Distance to nearest: Well /S72f Foundation Zbd ` Property.Line 4 DISPOSAL PONDS ❑ iI 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 i 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, 1 shall not employ any person in such manner as to become subject to workman's compensation-laws-of-California.GContractor'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'fo w' orkman's compensa- tion laws of California." f The applicant must call for all required inspections. Complete drawing on reverse-side. Signed X Title: (�671i(�i_. Date: 9 OR� EPARTMENT USE ONLY �Ptpr Accepted by Date Area Z— ut Inspection by Date �� inal Inspection by t Data2G1 Aditiona m ts: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i • FEE INFO AMOUNT DUE t AMOUNT RE[M}ITTED CA R RECEIVED BY DATE PERMIT'NO. i +.EH13-24IREV.1/nb1 EH 14-26 r��]O °o-O 1'