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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I. , 1601 E. HAZETON AVE., STOCKTON, CA Telephone {209) 466-6* PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ' J 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 1 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: x Job Address rCOYNo 5-�}1�,', , 43z LCA I+(3Lt6�n11tie ,� City SkVC1h Lot Size ' PM Owner's Name O o 1 4�0' = Address fZZI i hl 41' 1 fit- 6644"009A ,I hone - J Contractor�� 60Y p0Y4�1_M Address Idl 97�YErO��) )'YJrlra�r„,�� .License No? 90 '` _ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ � DESTRUCTION ❑ F, PUMP INSTALLATION ❑ "+ SYSTEM REPAIR ❑ OTHER7❑ + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION y AGRICULTURE WELL OTHER WELD - {' PITS/SUMPS * = INTENDEDUSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ci Industrial C3 Open Bottom ❑ Man# ca Dia. of Well Excavation -__J V,a Dia. of Well Casing L .' ❑ Do estic/Private a. X Gravel Pack ❑ Tracye _Type of Casing ��- p'Specifications} �7� j1 tD Other y .❑ Delta r Depth of Grout Seal ! l Type of Grouts g�l / i r El Irrigation l �� pprox. a th 0"Estern 1Surface SeaLlnstalled by Repair Work Done ❑ Type of Pump H.P. F",-y -. ..-._� Ji Sttate Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth _;r:' iller Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION O' DESTRUCTION ❑ (No septic system permitted if public sewer is h'w alXJry available within 200 feet.) Zlnstallation will serve: Residence— Commercial_ Other Number off living units: Number of bedrooms Character of soil to a depth of 3 feet: Zv�;. — ,Water-table depth s f SEPTIC TANK ❑ Type/Mfg /14 rMl'N _ Capacity i yNo. Compartments PKG. TREATMENT PLT. ❑' =^ t +; off " t 1 �F _ Method Disposal r Distance to nearest: I Foundation 9 Property Line LEACHING LINE ElNo. & Length of lines �g Total length/size (� FILTER BED ❑ Distance to nearest: We r CFoundation) ' Property Line f SEEPAGE PITS ❑ Depth ize ' Number SUMPS. ❑ Distance to nearest: Well a Foundation I Property Line DISPOSAL PONDS F-1 I hereby certify that I have prepared this application and that the world will be done in accprdance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I � 4- E 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 not employ any person in such manner as to become subject to workman's compensation laws 6f California."Contractor's hiring or sub-contracting signature { certifies the following: "I certify that in the performance of the work for6hich this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m all for all require? spec' 1s. C atza drawling on reverse side. -Z _ Signed re Title: t/ed Date: FOR DEPARTMENT USE ONLY Application Accepted by Date `�' �'`� e Pit or Grout Inspection by Date Final Inspection by Date Additional Comment -A&I? © � f XStk 466-67$1 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMiT`ND. �R + 90 EH 13-24 4REV.+/a 5) i A �Z EH 14-28 3_ •� �l�S r$3