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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 0-5 .. Telephone (209) 466-6781 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 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 Distri t. 104 4 L Ile L°4 040 2b Job Address S. e icCity T,�2s9-- „ - Lot Size A PM p Owner's Name __!a y.S //17�'G ��, .._ Address 42,6) T47/O —"i,4AI L ,fl/7etY f' Phone cif �a/p Contractor > L{fd� Address_-/ A]. f4A—'L_&4C7_ License No._~ _Phone 7 N1 TYPE OF WELL PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FI_D. PROP. LINE ! FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f"1 Public ❑ Other n Delta Depth of Grout Seal Type of Grout I i Irrigation _..Approx.-Depth I ] Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') to Depth, Filler Material (Below 501 _ �. TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i 1 DESTRUCTION [ I (No septic stem permitted if �' P Y P public sewer is available within 200 feet.) Installation will serve. Residence_ Commercial__e Other Number of living units: Number of bedrooms C Character of soil to a depth of 3 feet: SEPTIC TANK T Water table depth Type/Mfg -POLL Yq 9 _ Capacity 11a pQ _ No. Compartments �. a PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well A049 z Foundation_ .�0� �' Property Line JW z� LEACHING LINE M_'No. & Length of lines ge, Total length/size FILTER BED ❑ Distahce to nearest: Well. Foundation 30f1-tllProperty Line ±fov f' SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation f Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done`in accordance with San Joaquin county ordinances, state taws, and 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."Contractor's 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 California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: . Date: FDR DEPARTMENT USE ONLY Application Accepted by Date +- Area 1 �v Pit or Grout Inspection byData Final Inspection by - ' Date�z� � j f Additional Comments: �Cm _ z` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE A INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVCK ED BY DATE PERMIT'NO. a.EH 13-291REY.!/H51 EH 10-20 // 7lP U