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APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,-STOCKTON, CA d ''Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED :E} I(Complete in.Triplicate).d11.,. - F, 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. _ Job Address�� , _�-t / _ Ci Lot Size � QJ PM Owner's NaYg '# Address (P Phone C5&9 J , �^"e' �1 - 4 Contract {-f' r11A-�AH&P.SS _ 747 t/ .. L'r 'License No.�39-S'22G Phone 3 G'3 S)0, TYPE OF WELL/PUMP: NEW WELL-[]---WELL_REPLACEMENT❑_,,.._,_-,__DESTRUCTION-©•— - -� - PUMP INSTALLATION Ll + SYSTEM`AEPAIR 10 OTHER Elter DISTANCE TO NEAREST: SEPTIC TANK k,-iSEWER LINES�< DISPOSAL FLD.' PROP. LINE FOUNDATION- _- AGRICULTURE WELL— —OTHER-WELL—PITS/SUMPS'— INTENDED USE TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS t" ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation ! i Dia-.,of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑�Tr ca y f Type of Casing Specifications ❑ Public LJ Other i] f} Depth of_Grout:$dal/ ." - I 7 Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State'Yo�kb ne_ { Well Destruction ❑ Well Diameter Sealing Material-(top W) I Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION e DESTRUCTION ❑ INo septic system permitted if public sewer is �l available within'200-#eet. Installation will serve: Residence I.� Commercial Other s Number of living units: Number of be t I , Character of soil to a depth of 3 feet: _- �t.� _ rI i:i- Water table depth ' SEPTIC TANK ElType/Mfg ! Capacity 1 No. Compartments PKG_ TREATMENT PLT. ❑ r Method of Disposal' Distance to nearest: Well Foundation Property'Line LEACHING LINE Tr-'-No. & Length of lines I o Total length/size X r FILTER BED ❑ Distance to nearest: Well ,SD Foundation 10 Property Line 5 { SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest':''��i+-=WeIIz,�QI� Foundation- Property Line DISPOSAL PONDS ❑ JJ I hereby certify that I have piepared this application and that ifte work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 1 tt Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work-.for which thisermit is issued,\1 shall-not employ tQF p y an y person in such manner as to became subject to workman's compensation laws of California." Contr�ctor's�hiring orlsvb�c2intracfi?ig sign`dturet 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 11 for all re 'red inspections. Complete drawing on reverse de. Signed X Title: V • Datet� FOR DEPARTMENT USE ONLY Application Accepted by I Date Area Pit or Grout Inspection by Date ZrFinal Inspection by Dat { Additional Comments: 6 if!" i ❑ Stk 466-6781 _V_Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH "RECEIVED BY DATE PERMIYNO. + EH 1324 SREY:1/w 5y 'r EH W28 f i