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APPLICATION FOR PERMIT SAN JOAQUIN' LOCAL HEALTH DISTRICT r 1601 E. HAZEI_TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAWFROM DATE ISSUED ' Er (Cornpleie 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address _/ 16 /V,. % !°' ��'' - U ' City" � Lot Slze PM—_— _ Owners Name �� v ' 1 Address' ' ' Q' `�- 1]L�'i Phone - — Conlractof J� iL fddd_ �c C7rr F 1�. _ Address ./ �laia-1 License No,&_2Wa62 Phoneg(r,�-�U I TYPE OF'WELL/PUMP: NEW WELL Cl WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ . OTHER ❑ '• DISTANCE TO NEAREST SEP-TaC TANK — SEWER LINES _ DISPOSAL FLD, '_ PROP. LINE FOUNDATION``' = AGRICULTURE WELL __ OTHER WELL-- PITS/SUMPS i I INTENDEDrUSE TYPE OF WELL PROBLEM A -RE k--&O_—NSTR�UCTION SPECIFICATIONS O Industrial[ 1 Open Bottom O Manteca Dia. of Welt-Exca anon Dia. of Well Casing — "l Domestic/,Private 171 Gravel Pack O Tracy Type of Casing_ Specifications ❑ Public ❑ Other 0 Delta Depth of Grout Seal of Grout n Irrigatioq?—Approx. Depth ❑Eastern Surface Seal Installed by__ p� I Repair WU Done fl Type of Pump - __— � H.P. — _ State Work bone _ Well Destruction J Well Diameter —) Sealing Material Itop 501 — Depth _ . I Filler Material (Below 50 ' _ . _ 6 ') TYPE OF SEPTIC WORK:. NEW INSTALLATION 7EPAI /ADDITION t r DESTRUCTION [J (No septic system permitted if public sewer is I available within X00 feet.) i Installation will serve: Residence _ _ Commercial _ Other Number oPiNdng units.`_s_ „Number of bedrooms Character cif soil to a/opth of 3•60 . + c_ a - ,-+:^ I —Water table depth_. �.. SEPTIC TANK / 0 Typo/Mfg __. r 'Z' Capacity No. Compartments t —. i PKii. TREATMENT PLT. ❑ j�!}r}! Method of. Disposal _ Distance to nearest: Well . "�Z,`l',Foundation Property Line r. LEACHIN L NE ❑ No. & Length of lines _ . r " Total length/size_.. 1 FILTER/BED N n Distance to nearest: Well _ Foundation — Property Line �y SEEPAGE PITS o Cri Depth _ 95 —Size _ sem—.' _ Dumber SUMPS ❑ Distance to nearest: Well _15k5'— Foundation s—_ Property Line LY DISPOSAL PONDS (7 I hereby carts y that I.7have prepared this application and that the wofk will be done in accordance with San Joaquin county ordinances, state laws, .and - rules and regulations of the San-Joaquln_Local-Hoalth-District, Homeowner or'licerikd agent's signature certifies the follDwing: "I certify that in the performance of the work for trviiich this permit is issued, I shall not 1 employ any person in.stich manner as to become subject to workman's compensation laws of California." Contractor's hlrind-or sub -contracting signature certifies the following:" 1 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" — -4 The applicant music for 11 r uired inspections. Complete drawing on reverse side. I SignedX _� � .- Title: V. P,`Date:fJi `�C_�. FOR D ARTMENT USE ONLY Application Accepted by _ DatelV ._ Area ' — r V7 (2 or Grout Inspection b�% _ Date ._ Final Inspection by __Date � � U Additional Comments: G Add nts'----- F1 Stk 466.6781 ❑ Lodi 369-3621 11 Manteca 823.7104 ❑ Tracy 835-6385 1 Applicant - Return all copies to: Environmental Health Peimit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0, INFO CASH -_ EH 13-24 (RFV. 1' 05: % 1 EH 1 4.20