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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 44 3 2,5City -S roC+�� Lot Size PM Owner's Name I�f�Yn Ort.. Ce Address 01D S. �6C q0r'&G 414 , LQJ�,.�6 Phone fl 368W A .31 I E G Address y116W G/iP_I S�(Sr, �oN� ^'aq y Contractor License No. (vY3 Phenel TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -1k."PormAy w I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER N I 11T3(3 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 :I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation atop rOfC, it 11. Dia. of Well Casing ✓� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PV C 5 Z14 H 0 Specifications * Public ti Otperr ^ Cl Delta Depth of Grout Seal Type of Grout V_ XI a rc I)t . IrryyV t �mph�-F";J,. pp ox. Depth { I Eastern Surface Seal Installed by Vvt I ep it Wo k Done ❑ Type of Pump H.P. State Work pone_ e►fhi�h�� ' Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC RK: NEW INSTALLATION 1.1 REPAIR/AODiTION I 1 DESTRUCTION i o septic system permitted if public sewer is available within 200 feet.) i Installation will serve: sidence_ Commercial Other Number of living units: Number of bedrooms J i Character of soil to a depth o feet: Water table depth ' i SEPTIC TANK ❑ Type fg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to n est: Foundation Property Line LEACHING LINE ❑ No. &>Length of es Total length/size FILTER BED ❑ Distanearest: Foundation Property Line SEEPAGE PITS I I D th Size Number SUMPS ❑ Distance to nearest: Well Fo ation Property Line DISPOSAL PONDS 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 certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not j employ any person in such manner as to become subject 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." i The applicant must call Sor all required inspections. Complete drawing on reverse side. Signed LX % 1 _ ce kip ti n f• a n Title: ro fQ 0 Z0 N f r Date: 1^Vt�[P�F�R dEPARTME 7 USFONLY! [DYyt�pq� Application Accepted by Date14 FV Pit or Grout Inspection by Date Final Inspection by Date Z�23 Additional Comments: ❑ Stk 466-6781 11.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 FEE INFO AMOUNT DUE y�AA�MOUNT REMITTED CK H RECEIVED 6Y DATE PERMIT'NO. + EH 13-24(REV.i/R5) �j �� - EH 14-26