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"i APPLICATION FOR PERMIT >Y T~ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FR DATE ISSUED {Complete in Triplic te? � i Application is hereby made to-the San Joaquin Local Health District for a permit to can truct and/or install the work herein described. This application is made in compliance with San Joaquin.Couhty Ordinance No. 549 for sewage or No. 1862 or well/pump and the Rules and Regulations of the San Joaquin Local Health District. ' Job Address ✓rte CYl-VI-1 lV *C/ City Lot Size PM �Y�9G COvtt�T)' CLo&P Address ' Phone Owner's Name I� ContractorI�Mr/jpy >r Sa/Y _`Address License No. f Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ' DESTRUCTION ❑ ...+... PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE T NEAREST: SEPTIC TANK SEWS LINES DIS OSAL FLD. _PR P�LINE FOUNDATION "AGRI ULTURE WELL OTH R WELL PITS/SUMPS t I TENDS U TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFI ATIONS t ❑ Industria! ❑ Open Bottom ❑ Manteca fi Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ rivate Gravel Pack - ❑ Tracy" i Type of Casing Specifications ` i'1 a lic (� her ❑ Delta ' Depth of Gro t Seal Type of Grout _ I I Irrigation f w �_ rax. Depth 11 Eastern { Surface Seal Installed by Repair Work Hone ❑ Type of P p H.PP'' State rk Done _ Well Destruction ❑ Well Diameter' `O'kea(ing Mattel Itopf50'1 ; Depth Material Fn TYPE OF SEPTIC WORK: NEW INSTALLATION I] REOAIR7 4LDDITION DESTRUCTION I I INo eptic system permitted if public sewer is avail ble within 200 feet.) Installation will serve: "Residence— Commercial= O er XV4C Aq7" + , _,,,.,Number of living units: Number of bedrooms" V4 r ��jjb wp�Cha►ac ter of soil to a depth of 3 feet: L ' 4dA/k7 ater table depth f . , V TANK ❑ Type/Mfg pacity N : Compartments V r� PKG'TREATMENT PLT. ❑ _ Me Hod of Disposal Distance to nearest: Well Found Property L e • �a LEACHING LINE ❑ No. & Length of lines Total length/size �A FILTER BED CJ Distance to nearest: Well Found tiara y0 Property Lin SO s: SEEPAGE PITS I I Depth Siza Number ' SUMPS L,J Distance to nearest: Well Found ition Property Line DISPOSAL PONDS ❑ hereby certify that l have prepared this application and that the ork will be done in accordance with San Joaquin ounty ordinances, state laws, and G 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 whi_h 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 h ring or sub-contracting signature r certifies the following:'.'I certify that in the performance of the work for which this permit is issued, I shall employ persons ubject to workman's compensa- tion laws of California." The applicant m t call for all required inspections. Complete drawing on reverse side. Signed X Title: Dat DEPARTMENT USE ONLY Application Accepted by Date rea // Pit or Grout Inspection by .Date Finale inspection by Date 49� 5 Additional Commen_W ❑ 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 LL FEE AMOUNT DUE AMOUNT REMITTEDK H RECEIVED BY DATE PERMIT"NO. INFO r� + EH 13-24(REV.:,i n 5) EH 14.28 r � ,