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l� APPLICATION FOR PERMIT 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 Rd, City G Lot Size pM 1 Owner's Name Q rcIO2�„$ C u Address Phone Contractor cc � S Address C,-C License.No. b aq Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL RE LACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ Ir SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation IDia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ,`. Type of Casing Specifications ❑ Public ❑ Other ❑ Delta De th of Grout Seal + ,r/• _ p Type of Grout ❑ Irrigati nl#Itil --Approx. Depth,""O Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump Y H,P. State Work Done Well Destruction. Well Diameter � w� 11 Well f , Sealing Material (top 50') Depth -�#r Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ , REPAIR/ADDITION ESTRUCTION ❑ (No septic system permitted if public sewer is •� T �--. M ) able within 200 feet. Installation will serve: Residence— Commercial Other Number.of living units: Number of bedrooms ""' r 47 Characterrof soil to a depth of 3 feet: + M -�j Water table depth SEPTIC TANK_ ❑ Type/Mfg Capacity �' No. Compartments Q PKG. TREATMENT PLT. ❑ € `44-Method Method of Disposal Distance to nearest: WellFoundation Property Line LEACHING LINE' ❑ No. & Length of lines Total length/size FILTER BEDS ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITSr `r is Depth Size - Number.r SUMPS ❑ Distance to nearest: Well ,fi Wk JeSundation D r Pri operty Line t ' r r►^ DISPOSAL PONDS ❑ ,lyp y,U,C-�+ i +w.,,,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: "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 of California."Contractor'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 to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on,reverse side. Signed Title: � a-tom_ Date: S -5� FOR DEPARTMENT USE ONLY J Application Accepted by. f J ,. , � _ Date � �- � Area Pit or rout Inspection D� N_P :n�IR 4 Date Final I sn pec4on by -� Date 5'�"W Additional Comments: ❑ 5tk 1B78i El Lodi 369-3621 13 Manteca -823-7104 ❑ cy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO ��`` 69. RECEIVED BY DATE PERMIT'NO. + EH T3-24(REV.I/e 5) Ur /' J. 7 EH 5426 ` '� �S}•1 _57 / ��S