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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTONFAVE., STOCKTON, CA Telephone {209} 466=6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' -,(Complete. in Tri Ilcat6} ' '" ' 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 I Local Health District. _M„ $ f, ILY�'"Cl�E+fi.�-r�C, [ til .. . Job Address ? ,O ity I,,., 'Lot Size PM Owner's Name f Address � �- �7: O 9S2140 Phone �o — .02Z Contractor PurYlanceiJFlllers Droll iA�. �jX C4�[ LIA/DE�/ ; TYPE OF WELL/PUMP; ,License No.��Phone �7 3SS NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ k PUMP INSTALLATION IC DISTANCE TO.NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ _.^7 ✓1. r;. .. , '_ .-;,_,,o , SEWER LINES _ _DISPOSAL FLD. PROP. LINE "FOUNDATION"' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial Jill Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing �` ❑ Domestic/Private D Gravel Pack ❑ Trac Y Type of Casin k4je `I El Public ❑ Other g Specifications i` ❑ Delta al � � If l�1 Irrigation ---Approx. De�th'n ❑ Eastern Surface Seal installed by _I Repair Work Done 1-2Typeof Pump r urc�J i� H P -.]jQjZZ Well Destruction ❑ Well DiameterState Work Done Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is Installation will serve: Residence_ Commercial_ Other available within 200 feet) Number of living units: Number of bedrooms (� Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Watertabledepth PKG. TREATMENT PLT. ❑ Capacity ' No. Compartments x ` Method..of'Disposal Distance to nearest: Well u _ _ Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED — ;Total-length/size,--- ' ❑ Distance to nearest: WellFounun �t ! dations:> k Property'Line n SEEPAGE PITS ❑ Depth Size T r SUMPS [ Number }fl Distance_ to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line - j 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: 1 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," Contractors 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 em to tion iaws of California." p y persons subject to workman's compensa- The appli ra must cal f all r fired inspections. Complete drawing on reverse side. r Signed t Title: i i Date: _3�1 ' FOR DEPARTMENT-USE.,ONLY-;" """""--....�- - Application Accepted by tA DateArea Pit or Grout Inspection by �' v Date Final Inspection by" Date Additional Comments: q, y ❑ 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 96201 FEE INFO AMOUNT DUE AMOUNT' REMITTED CK CASH RECEIVED BYEDAETE NO. CASH + EH 13-24(REV.1/8 57b EH 1426 �-S•"�'� -