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W APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE E ON AVE., STOCKTON, CA Teleph_ohe (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) f 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 ,�tLoocal Health District. Job Address 1��9�' ./� �0� �� City of e;!> I Lot Size ZD PM Owner's Name Address SJE Phone Contractor /G4=!�!J3L7 6. 14VdZFD --Address f7. 427494 6,AP- - License No. Phone -35P 7 TYPE OF WELL/PUMP: NEW WELL LJ WELL REPLACEMENT ❑' DESTRUCTION ❑ --PUMP INSTALLATION ❑ y SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ? DISPOSAL FLD- ROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONAPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weg,�zcaVaiion Dia. of Well Casing ❑ DomesticIPr ateLJ rage acd-__� ❑ Tracy Type-of Casing Specifications 1-1 Public ❑ Other 171 Delta -'"f1Depth of Grout Seal 'Type of Grout - I I'Irrigation 4 o --Approx. Depth-J.. Eastern Surface Seal Installed by Repair Work"Done ❑ Type of Pump , H.P. State Work Dane _ ~ Well Destruction. " ❑ Well Diameter Sealing Material (top 501 " Deptb Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION DESTRUCTION I i INo septic system permitted if public sewer is 7, available within 200 feet.) Installation will serve: Residence Commercial Other -Number of living units:--I— Number of bedrooms Characterof soil to a depth of 3 feet: Ai�D"�- =L,iy4�+►�-=';f= 42iR=r�isl .4 Water table depth l' Capacity No. Compartments SEPTIC TANK EI Type/Mfg PKG. TREATMENT PLT. ❑ r� Method of Disposal r Distance to nearest: W I FounBatibn''_'�; ---Property Line LEACHING"CINE Pr"'No. & Length of lines I Total length/size S' FILTER BED ❑ Distance to nearest: Well: Foundation 3 G �. Property Line fWf1 SEEPAGE PITS ' f Depth 77s" Size a ' Number i SUMPS L7 Distance'to nearest: Well AMFoundation /6�d i Property Line 2-Oe 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 Df$trict. x Homeownerorlicensed agent's signature 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•becofi;Zblectio 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 io workman's compensa- tion laws of California." The applicant must call or all required inspectio s. Complete drawing on reverse side. o Signed X Title: La 11`1� Dater 'SY r EOA_D.EP_ARTMENT.USE_ONLY.;;,-- l- - - ---g—_-- - , Application Accepted by �/69-n_ I *- - Date I�/�y/-�! Area ^f Grout Inspection by Date Final Inspection Spit byfi--e�d rel Oat - I Additional Comments: ❑ Stk 466-6781 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK F! RECEIVED BY DATE PERMIT'NO. `. INFO CASH �f/ r.EH 13-24 UIEY.1/r151 PER! EH 14-29