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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. ,HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r. t,,,.: Y 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. 4,0 7 l / r. 2-.4 z8�9W¢ f., Job Address �1_/.�/�' �� Q ,'Ll S-- - City Lot Size / PM Owner's Name D i .C.�E Y — -Address _?c P,Z 7- Z& Phone ContractorJO! Kl� _,� jib] ddrress icense No._& Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION l(l�3YSTEM REPAIR +O OTHER Ll pISTANCE TO NEAREST: SEPTIC TANK SEWER LINES�i { DISPOSAL FLD. _ PROP. LII 't ( FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS SUMPS INTIFNDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f• 9 ❑ Industrial ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation / G.� Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �� Z Q Specifications ❑ Publ, Q Other ❑ Delta Depth of Grout Seal -r Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Syr{ ce Seal Installed by Repair JVork Done Al Type of Pump 1 �� H.P. iii State Work Done /�/ST/ LIL, Well Delstruction ❑ Well Diameter Sealing Material (top 50') dill' SEAL 7C� e�,o Al ,�, 'r f�/�J[�AT Al Depth Filler Material (Below 50') JVZU_ ZO ,1�iPlt'IESf/C lel TYPE O'F SEPTIC WORK: NEW INSTALLATION 171REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if puhlib sewer is - t available within 200 feet'.] Installation will serve: 'Residence Commercial_ Other Number of liviifg units: � Number 16 dooms i Character of soil to a depth of 3 feet: '74 -Watdr{ttable depth 1 SEPTISTANK ❑ Type/Mfg Capacity- j''No. Compartments I V 1 PKG. TREATMENT PLT. ❑ ` Method of Disp.,Al l.t �1 t Distance to nearest: -Well X�N Foundation_- Property LEACHING LINE i ❑ No. S Length of lines Total length!size FILTER,BED ❑ Distance to nearest:. Well Foundation Property Eine SEEPAGE PITS - 1 ❑ Depth Size Number SUMPS .❑ .Distance to nearest: Well Foundation Property Line Y DISPOSAL PONDS ❑ e, I hereby certify that I have,prepared this application and that the work will be done in accordance with �an Joaquin county ordinances, �tate laws, and rules and regulationseof the San Joaquin Local Health District. . Home owner or licensed agent's signature certifies the following: "I certify that in the performance of thillwork for which thislzzpermit 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-contrIcting signature certifies he following. "I certify that in the performance of the work for which this permit is issued, I shall ploy persons subject to workman's compensa pr tion IawS of California." -- -- - � The applicantMfor reqAe uire inspections. Complete drawing on reverse - 1 v t j signed X __ Title: a Date: V�/e�/S4, �FOR DEPAR HENT USE ONLY �• !/a I Application Accepted by 1 Date Area � � Pit or Grso nspection by to Final Inspection by F t Datpt � A di nal Comments tk °466-6781 ❑ Lodi 369 3621 ❑ Manteca 104 ❑ Trac pplican'- Return all copies to: Environmental Health Permit/Services 160{1 E. H a z e I t o n Ave.,�P.O�oB tk., CA 952 11 L—FEE"`--�i3T-bo AMOUNT REMITTED � CASH RECEIVED 6Y DATE PERMIT NO.4�S INFO . IV� `+ EH 13-24 IRM �1�� ' ��' EH 1428 L1(O J