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` APPLICATION FOR PERMIT SAN JOAQUIN .LOCAL:HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .� (Complete in Triplicate) r 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 r' # City Lot Size.(- PM. y r. r I I �J s Owner's Name Address !V PhoneMH (033.2 •a Contract /L ` Address License No.-J29274, Phone (Wo �o OF WELL/PUMP: NE�,,N��c.,,WELL.C �r WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALOMON,❑4 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARE TIC?TANK L---SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDA I AGRICULTURE WELLr OTHER WELL. PITS/SUMPS INTENDED USE TYPE OF WELL P AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom' ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel+Pack -❑-Tracyu Type o Specifications ❑ Public ❑ Other,0 C� ❑ Deli� ! $ # t epih of Grout Seal Type of Grout ❑ Irri ation r 4_ u g —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump # H.P. Vii, State Work Done_ Well destruction '❑ Well Diameter = Sealing Material(top 501 Depth }- Filler Material (13elowk50') TYPEjOF SEPTIC WORK: NEW INSTALLATipN REPAIR/ADDITION ❑ DESTRUCTION C1 (No septic system permitted if public sewer is J (} f� available within 200 feet.) A t Installation will serve: Residence_` Commercial_ Other s _ � Number of living units:—/— Number of droorn s I Character of soil to a depth of 3 feet: Water table depth +D ' SEPTItC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Q Method of Disposal ` Tstance to nearest: ell Foundation I property Line >.!!C: _ r "^L:++t TEACHING LINE INo. & Length"of lines �k ^ �o "1 Total len th/size B X. AaFILTE BED D Dis ance to nearest: I_�D r Foundation T _ p operty L SEEPAGE PITS Depth Size N (f t iSUM ks ❑ Distance to nearest: Well Foundation — roperty Line,h' � I DISPOSAL PONDS ❑ t .3 VII Ihereby-certify-that•l-haveprepared-this-application and-that the work will be done in accordance with San Joaquin county ordiria'nces, state laws, and (,rules and regulations of the San Joaquin Local Health District;: - N- ,Y Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ,any-person in-such manner-ail;;become•subfect to workman's-compensation laws-oi California." Contractoes 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 ust call for al quir d inspections. Complete drawing on reverse sid I Signed X ,Title: ✓'1l1 r Daw FOR DEPARTMENT USE ONLY ppy�� Application Accepted by Date �Z ~ir�E' Area Pit orGrout Inspection by Date Final Inspection by ate f Additional Comments: ❑ Stk; 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. \ /-'3�724 TREY.i/a5i 77d- Q7 r