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`. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL;HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,.STOCKTON, CA r Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED '"' s�.. (Complete .in.Triplicate) Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein de cr bed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 far well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address - ti',h� ,, r ! s ;..' "I, r A ¢. t, �~ l City �r'C�9 Lot Size .6 G PM Owner's Name NA —" ' Address -- � � - �— - -"Phone T.�" r Contractor_._ �, ✓�, �G Gc;�2 Address 17>oa /,y7 ' TYPE OF WELL/PUMP: License No r2—,S-ka Phone_ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ y, i UMP-INSTALLATION-0--�,�.e,,.-SYSTEM-REPAIR--P—_ �U DISTANCE TO NEAREST: SEPTIC TANK OTiifR`lp SEWER LINES' DISPOSAL FLD. PROP. LiNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 1P Open Bottom ❑ Manteca Dia._of Wel! Excavation Dia. of Well Casing ❑ Domestic/Private p Gravel Pack ❑ Trac ° � '�' g r y " Type-bf Casin �t El Public Q Other �' ' �' g t ,. Specifications '❑ Delta Depth of Grout Sea! 13Irrigation �Approx. Depth ❑ Eastern Type of Grout Surface.Seal Installed by A Repair Work Done "❑ Type of Pump H P Well Destruction ❑ Whell Diameters State Work bone_ ( - Seating Material"(top 50') 1 Depths Filler Material (Below 50') } TYPE OF SEPTIC WORK: .NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ fNo septic system permitt;ifpub;1icsewer is fi 4 rt available within 200 feet.} Installation will' rve: Residence_�CorArcial Other r Number of living units: Number of bedrooms Character of soil to a depih of 3 feet: SEPTIC TANK„ 8i Type/Mf 1111 D � Water table depth j Type/Mfg ter' Capacityo-D No. Compartments i PKG. TREATMENT PLT. b 1 i �] T1 7- of Disposal 3. Distance to nearest: i Well ( �--�_ Fipundation Property Line i LEACHING LINEl t ❑( No. & Length of lines Total length/size l Fr f FiLTER BED ❑ Distance to nearest: W�I d.. X P r 4 - �_ Fourldatioii""�- --,-- Property Lisle 111 SEEPAGE PITS - ❑ Depth Size `* r' (2 SUMPS Nu'rlmber � Distance to nearest:- Well 1S^O�' Foundation cS DISPOSAL PONDS ❑ v'� dJ Property Line SFS �Si ♦i,_ � hereby certify that I have prepared this application and that the work wiA-be-dgr►Q ><.accordance w6'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 hecome subject to workman"s compensation laws of Califor4ia." Contractor's hiring or sub-contracting signature i certifies the following: "I certify that in the performance of the work fors hich this permit is issued,Ishall employ persons subject to workman's compensa- tion laws of California." I h The applicant must call for r required inspections. Complete drawing n rev r� side. }f Signed A Title:. ,• �,,�i.. i-, , Date: L= $ FOR D P RTIU�N USE ONLY 1 Application Accepted by $ ` - '�' Datey Areay� Pit or Grout Inspection by Date ' F. al Inspection by 4� Date Additional Comments: s Q 5tk 466-6781i-' ❑ Lodi 369-3621 ❑ Manieca 823-7104 ❑ Tracy 835-6385, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O; Box 2009, Silt., CA 95201 r F EEE , AMOUNT DUE.:a -A T EINITT�D--.�. CK. `INFO C,4SH "�vRECEIVED 6Y: -DA-TE ♦ EH 13-24(REV. EH 14-26 - -