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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES VYEAR FROM DATE ISSUED {Complete in Triplicate} �. ein Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the herdescribed. 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 -3 0 Il. City Lot Size PM r `�,S l( Owner's Name Address' „ 3Id.` 0, Phone `3 .eV+'e y r / Contfactor • 1 \QtD1�1 Address © Y1 C`�Z G {v 3'� 3 'cense No. �V q hone_ TYPE OF WELL/PUMP: EW WELL 0 ii WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ ' SYSTEM REP ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTU ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROB AR CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom ❑ Man�t Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack C] Ta�cy i pe of Casing Specifications f 1 Public Cl Other / Delta Dep of Grout Seal Type of Grout---- u, rout _ I I Irrigation -Approx. Depth I.) Eastern, Surface 'I Installed by Repair Work Done ❑ Type of Pump H.P. -^ State Work Done . Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 50') r� TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 RI-PAIR/ADDITION i.J DESTRUCTION (No septic system permitted if public sewer is (Jv available within 200 feet.) installation will serve: Residence— Commercial Other, O ; _w Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity . No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal j Distance to nearest: Well " Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size �} FILTER BED ❑ Distance to nearest: Well Foundation Property Line '} 7 SEEPAGE PITS 11 Depth Size Number O SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ J 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 st I for all required ins ctions. Complete drawing on reverse side. _ ! Signed X Title: Date: FOR DEPARTMENT USE ONLY q w Application Accepted by Date + l Area-.-.. Pit or Grout Inspect by Data Final Inspection by Date Additional Comments: {� I+ b f l_F-, e IL y VL e.f i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca '+823-7104 ❑ Tracy 835-6385 # Applicant - Return all copies to: Environmental Health �Permit/Services 160 E. Hgzalton Ave., P.D. Box 2009, Stk., CA 95201 i ll e-/� Iy c� �v� r i'`�fFitt var'r/G�dl INFO AMOUNT DUE AMOUNT REMITTED CK 40 RECEIVED BY DATE PERMIT'NO. r•EH 13.24 1REV.1?9 5) 3� �� - �/�•G/` _ EH 14-28