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5 ' 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.' ` r. Job Address L/ L�L 4 ��/ City 4191�401P Lot Size PM Owner's Name � 7' /yr elm 1061(y Address C`f I I 4�7J -3�XJC 1� Phone��y 9,4,- 2o Contractor (SJco� �h'�ta fdr�ess`U�l fa� ,tY!+ 'License No, � � Phone ��`J�/� s TYPE OF- 1EL ❑�*+^rt--�•�WELL L^ AEPL`ACEIVI NT.❑ DESTRUCTION ❑_ �.., ` f PUMP INSTALLATION ❑ SYSTEM REPAIR..❑ _49 OTHER ❑ pDISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ,} FOUNDATION AGRICULTURE WELL A OTHER WELL PITS/SUMPS ` :.'. : a=tea_ : INTENDED USE ` TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS EllndCtstrial ' O Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing µ ❑ Domestic/Privaie f7 Gfavel Pack,- ❑ Tracy Type of Casing+"'s _ Specifications f flePublic: ❑ Other ❑ Delta Depth of Grout Sea! Type of Grout a I. I 11;rigation, "Approx. Depth I I Eastern Surface Seal Installed by 4 Repair'Work Doe ❑ Type of Pump H.P'' _ _ State Wgrk Done_ Well Destruction y xt.❑r/�WellTDiameter Sealing N-aterial_Itop'5011 x " Depth n Filler Material (Below 501 TYPE OF SEPTIC WORK:+ NEW INSTALLATION I•'`Iy Ri=PAIRl.AbDITION DESTRUCTION I 1 INo septic system permitted if public sewer is R i! wawa.. Installation w — �,. c °' y available within 200 feet.) Installation will senie: �sidence ._.Commercial_ Other .E� .w. ar i Number of living unit + --Number of bedrooms X t Character. f_s,il-,to• depthi`` 3=feet: .� .°� ♦ $ p - 94 �°ar. _ _ Water table depth SEPTIC TANK s ❑ $ype lfo,j I Capacity `' No. Compartments PKG. TREATMENT PL1T. ❑ k 'r�' Method of Disposal °y � F i ` Distance to nearest: Well Foundation Property Line "6 p CEAAING L;HNE r'`0 ❑ No. &'Length of lines ", 900' 9 Total length/size FI TgR*D ❑ Distance toinearest: Well ��`y 4 Foundation Go` -�/U t \ r Property Line SEEPAGE PITSillll!II"6fwl')I-bepth "' v Size Number SUMPS ❑ Distance toynearest: Well Foundation Property Line DISPOSAL PONDS ❑ { I hereby certify that I have preparedthis application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and A 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 parson 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 tI permit is issued;I shrill employ persons subject to workman's compensa- tion laws of California," al'4y4 'n a �'i �.iE '• �F aF-,a The applicant call for re it in ctions. Complete drawing on revs a side t, Signed. Title: t? Date: �17� - FOR DEPARTMENT USE ONLY Application Accepted by Date �—l n- 84? Area 0 r Pit or Grout inspection b S 4t 4 0 . 1, Pe y Date .. Finallnspectionby_} M �"` Date' _ J�f Additional Commt1G(COYr•d7.� ents: �� •+��,� ❑ Stk 466-6781 ❑ Lodi 369 f ❑ Manteea 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 FEEV AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE w PERMIT'NO. INFO q + EH13-24 IitEV.1/14 s) � �,...� J 71?7 9 EH 14-26 'HCl — / . 1 (J �p t