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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 4 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 s 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 Z/ r!!1 w re G rrtrZ5:� City <-JLot Size PM Owner's Name 244-16,6-'SI "7_ex,Q,? F.' Address ZZ `ll/ w cb e3 t/Z5t-- Phone Contractor's Name A tdGG� License No. `>li"B";2, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE jTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work-Done--fl---Typoof-Pump-- Well Destruction ❑ Well Diameter Sealing Material [top 501 i Depth Filler Material {Below 501 i r TYPE OF SEPTIC WORK: NEW INSTALLATION K, REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is f Ii — available within 200 feet.) nstallat - _ on will serve: Residence L� Commercial_ Other Number!of living units: Number of bedrooms Character of sail to a depth of 3 feet: 06, Water table'depth SEPTIC TANK ❑ Type/Mfg L, Capacity• JAZ No. Compartments ti•.a / PKG. TREATMENT PLT. " : r, -�=` ��_ - + El �� - Method of Disposal 0 Distance to nearest: Well, Y Foundationf Property Line C LEACHING LINE t( N6.'&'64 n_`gt_h of,dines F �6`F`7� Total length/size ,1;41 y� FILTER BED ;,❑ Distance 46 nearest: Well/n Foundation.,^ - �E Property Line \ Y SEEPAGE PITS ❑ Depth _Size —'Number q SUMPS `Tyf ❑ Distance to nearest: Well Found'�ation .- Property_Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done;in accordance with San foag6in county ordinances, state laws, and l 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."Contractors hiring or sun contracting signature certifies the following. I cern that in the performance of the work for which this il'"' " certify pe permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. 1 Signed X 3 z�. Title: _ F `I Date: F FOR DEPARTMENT USE ONLY i 3 Applicatiorf Accepted byDate Area J t, # Pit or Gro1)t Inspection by Date Final Inspection by e Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823=7104 ❑ Tracy 835-6385 t Applicant, Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F -FEE--- r r — ._ CK- T- *•� ` ^ ��^^ ---_1._. INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVEQ BY DATTEE PERMIT NDd . + EH 13-24(REV.101831 C7 O / -S ` EH 14-28 / "F