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APPLICATION FOR-PERMIT SAN JOAQUIN :LOCAL HEALTH DISTRICT 1601 E. HAZELTON.AVE., STOCKTON, CA Telephone {209} 466-6781prh PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED.. .j- �' t_, ti` ^- 1 ..y nf;;.)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 madein 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. . + atJ Job Address s r. I'"kAt 1f j ra City 5 7 .t 4 Lot Size_.. Owner's Name S' o• L `Address L'f�O�G°c 11?ef�T j_"S 7— Contractor's Name _r 4-o YZ. .iyee License No, Phone 97 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ;—-,.—T"PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ,DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DJSP_OSAL FLD._ PROP. LINE 4 FOUNDATION AGRICULTURE WELL -OTHER WELL PITS/SUMPS INTENDED USES . TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k 'Cl Industrial �'❑ Open Bottom ❑ Manteca Dia. of Well Excavation= f Dia. of Well Casing A❑"Domestic/Private El Gravel Pack' ElTracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal "- Type of Grout . L] Irrigation _.Approx. Depth ❑ Eastern Surface Seal lnstalled by ' i Repair Work Done ❑ Type of Pump H.P. 16VState Work Done Well Destruction...r..❑ Well-Diamete r= Sealing_Materiai 406 501 Depth Filler-Mat`erial-[Belo -50, TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION X DESTRUCTION Q (No septic system permitted if public sewer is / 4 available within 200 feet.) _Z Installation will serve: Residence— Commercial- Other Number of living : ' unitsNumber of bedrooms-�-� +. (0Character of soil to a depth of 3°feet: L-AfZ -` Water table depth SEPTIC TANK ❑ 'Type/ fM g Ca act f p ty No. Compartments PKG. TREATMENT,,PLT. 0---•=41 I 1 ; Method of Disposal ! I Distance to nearest: Well 124 Foundation I Sr � ` � � Q •` Property Line 4LEACHING LINE _'��No. & Length of lines — = Total length/size .; FILTER BED p Distance to nearest: ',Well 43Q! Foundation Property Line _3 ti SEEPAGE PITS' lir Depth , Size - 3 Number SUMPS , � L7- Oistance to nearest:, 'Well 1762 . Foundation - Q Property Line- -442 f DISPOSAL PONDS �r' ❑ "�,.� , ' I 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. i i 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 pennon 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 employ persons subject to workman's compensa- tion laws of Califomia." .The applicant must call for all required inspections. Complete drawing on reverse side. F in )Signed Title: - r '- .` Date: 11 41RI DEPARTMEN USE ONLY 1. ` Application Accepted by Date ��7� Area fJ - r Pit or Grout Inspection by Date Final In by Date Additional Comments: p # E ❑ Stk 466-6781 ❑Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6? f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVE1191Y PATE PERMIT''NO.' INFO CASH ' +EH 1344 IREV.101831 EH 14-28 S• 4 0