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i 4ND W� {.`"'�' ; APPLICATION FOR (PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEON AVE., STOCKTON, CA r Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,i , . ..,. (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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1851 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. n } Job Address Com + y Lot Size PM Owner's Name JC-Fp- 1Q ,L • v c7/e Address Phone�( h Contractor G� Address SSA C- License No. Phone-5" TYPE OF WELk-J.4'UMP: ij NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE,TO. EAREST: SEPTIC TANK SEWER ES ISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTU WELL OTHER WELL PITS/SUMPS ti INTfBfe• 3f-- YPE OF WELL PROBLEM AREA CO UCTION SPECIFICATIONS Li Industrial ❑ Open Bottom ❑ Manteca Pa. of ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Ca 'nti g-- ti-- ❑ Public i -' Specifications ❑ Other ❑ Delta` "-"""""'0ep"tFi of'Gr-o t`Seal pe of-Gro�t- ❑ Irrigation !! Ty !!Approx. Depth ❑ ern Surface Seal Installed by Repair Work Done LlTyp t of Pump H.P. State Work Done Well Destruction ❑ Weil iDiameter .. Sealing Material {top 501) 14 Depth $ Filler Material (Below 501 6 � TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewej is � available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: �M Number of bedroomstk } j Character of sail to a depth of 3 fees: _ .Water,;3able depth SEPTIC TANK ❑ Type/Mfg t" Capacity: No. Compartments PKG. TREATMENT PLT. ❑ • Method of Disposal i s Distance to nearest: Welt Foundation I Property Line LEACHING LINE ❑ No. & LengtN of lines t . E Total length/size FILTER BED ❑ .Distance;to nearest: Well Foundation Property Line j SEEPAGE PITS ElDepth { Site Number f SUMPS ❑ Distance nearest: Well i Property Line ,. Foundation I DISPOSAL PONDS ❑ ��_ ,� i �' I hereby certify that I have prepared,this.application and thathe work will be done in accordance with San Joaquin cc city ordinances, state laws, and : $ V rules and regulations of the SanCJoagdin Local Health 014trictc Home owner or licensed agent's:signature certifies the following: "I certify that in the performance of the work for whicl 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 gvork for which this permit is issued, I shall employ ry tion laws of California." �� i Persons subject to workman's compensa- _� cant mu t call for all required inspections. Complete drawing an reverse side. Signed Title: Date: 'mow I.Fgf PARTMENT USE ONLY - Application Accepted by f .1 Date Area 19 Pit or Grout Inspection by Mr f pale.j Final Inspection by Date 3 3 �f Additional Comments; ❑ 5tk 466-6781 ❑ Lodi 'X369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 i Applicant- Return all copies to: Enviroinmer al'Health Permit/Services 1601 E.Hazelton Ave., P.O. Box 2009, Stk., CA 95201 { FEE AMOUNT DUE . AMOUNT REMITTED K RECEIVED BYE INFO DATE PERMI'r NO. f + EH 13-241REV,1/85) I� U EH W28 '" IZ5 Ia' _ . v . _