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APPLICATION FOR PERMIT I t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 N V. T/4 4k'T'0/✓_- R2, City l??!,}//7M" Lot Size 6 PM Owner's Name /��ddress- JRZ3 2. P A!IP-A1 Phone y $44- TYPE-GF-WELL-/-PUMP:- d 4- 7 Contiactor_ "�sJ`�O_ `Address 7 J�• AI+��1-BGtiT License No. 2 Y Phone i TYPE-OF-WELL--/PUMP:.--NEW-WELL-El---WELL REPLACEMENT ❑ DESTRUCTION © i PUMP INSTALLATION ❑ a f SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑.-Industrial F ❑ Open Bottom _ ❑ Manteca Dia. of Well Excavation _ Dia_of Well Casing �� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public I1 Other 171 Delta Depth of Grout Seal Type of Grout_ I I Irrigation -Approx. Depth -I 1 Eastern, Surface Seal Installed by _ Repair Work Done ❑ Type of Pump • H. State Work Done Well Destruction ❑ Well Diameter '-Sealing Material Itop 50'1 1 Depth '\ Filler Material (Below 501 — L TYPE OF SEPTIC WORK: NEW INSTALLATION -REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is E available within 00 feet D Installation will serve: Residence_ {Commercial s: a Other X10/6) JC r` ((�>� Number of living unit :. •� - -Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg r?0- Capacity I2eFe2 No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Na. & Length of lines fl Total length/size '1'C o FILTER BED LI Distance to:nearest: Well/�0 r Foundation �j r Property Line SEEPAGE PITS JDepth �f Size T =F Number �r 5 SUMPS:l L�� Distance io nearest: 'well- 1��3 f Foundation �� F -Property Line 10Q_� DISPOSAL PONDS ❑ - --�^-- I.heteby certify,that I have prepared this application and that tFie work will be done in accordance with San Joaquin county ordinances, state laws, and mules and regulations-of-the San Joaquin Local Health`.Di3trict. " � ,-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 fl 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.' ,� . r The applicant must ca or:all�re4uir6d inspect s. Complete drawing-ori reverse side. Signed-X Title: Date: `. '_� FOR PART USE ONLY Application Accepted by * Date a Pit or Grout Inspection by Date, Final Inspection by Date Additional Comments: El Stk 466-6781 ❑ Lodi 369.3621 0 Manteca 823-7104 __ ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit&ervices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 IFEE NFO AMOUNT DUE AMOUNT REMITTED C K r ' cRECEIVED BY DATE PERMIT'NO. f-EH13-24fREV71-in51'. ..._ .Y°. - — _.... - �!/ /.�!R / Q / ��7 EH 14-26