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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 i PERMIT EXPIRES TYEAR 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. p Job Address �• �-/ i "`��" City Lot'Size 071 X I me,"PM J�r��irtvtat..� Qrf£rvr..� Owner's Name _Ahggj! S]L CA,JLI ,Address Phone t�Q - Contractor IY�/ w` CP�fSI- Address /716 1 to 4'a License No. Phone ! �� TYPE OF WELL/PUMP: NEW WELL LJ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION LJ SYSTEM REP ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE L OTHER WELL ''SPITS/SUMPS INTENDED USE .-TYPE OF.WELL_PR E<Suffac RUCTION'SPECIFICATIONS""" ❑ Industrial ❑ Open Bottom ❑ MantWell Excavation Dia. of Well Casing (] Domestic/Private ❑ Graver Pack -� Q Tra Casing Specifications M Public C1 Other eltaf Grout Seal Type of GroutI IrrigationI _-Approx. Depth I ],Easterne Sea! Installed by Repair Work Done ❑ Type of Pump F H.P. -- State Work Done_ Well Destruction r * ❑ Well Diameter-`- -% Sealing Material (top 501 h� Depth f, ` Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is TT { available within 200 feet.) Installation will server Residence_ Commercial— Other Number of living units: Number -of bedrooms 6' 1 Character of soil to a depth of 3 feet: Water table depth "'SEPTIC TANK ❑ Type/Mfg _ Xd No. Compartments ..__ PKG. TREATMENT PLT. ❑ �` `�.p Method of Disposal Distance to nea2`e'. ^, 114LT t roperty Line r � W pp - LEACHING LINE ❑ No. & Length of lin er I" To al I u UPI,Cd ngth/size FILTER BED ❑ Distance to.neareltlor(�'01�_�_ _ �o1�si Ndrr1"InS ��d `Property SEEPAGE PITS1 Depth w '3� -Size y I t Number SUMPS r 13 Distance to nearest: Well Foundation '"Property Line DISPOSAL PONDS 0- I 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 m� rules and regulations of the San Joaquin Local Health District, f• 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 must call for all required winspections. Complete drawing on re ver side. Signed X �rn�tA J b �, Title: 5f0 Date: FOR.OEPARTMENT USE ONLY I Application Accepted by � Date -� /6 S� Area ( 9 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: �� .{z.�r1 Q 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 95201FEE INFO AMOUNT DUE AMOUNT REMITTED A RECEIVED By DATE PERMIT'NO. + EH 13-21(R1V.)/[Ar) ti EH 14-28 • 4