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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZE T ON AVE., STOCKTON, CA 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 District. ll Job Address D City Lot Size PM 01 j� Owner's Name /r�n23- � Address ` �' —03 JLc r i • ;3/ !y� -; L:icensr N"o:/' •!—a—Phone' '"'"`Contractor - T ddress""'� TYPE OF WELL/PUMP: NEW OELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ F., L 3 j PUMP INSTALLATION❑ SYSTEM EPAIR ❑, OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWE LINES . r. ' DISPOSAL FLD. PROP. LINE j FOUNDATION AGRIC LTUREI ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom � ❑ Manteca Dia. of Well Excavation Dia. of Well C sing r] ' + ❑ Domestic/Private ❑ Gravel Pack # ❑ Tracy Type of Casing Specifications t .( I Public (1 Other Cl Delta Depth of Grout Seal f Type of Grout__. I ! Irrigation Approx. Depth 'L-.I East n ! Surface-Sean-installed by �^ I - f Repair Work Done-0 Type of Pump �' H.P. State Work Done _ { Well Destruction 0 Well Diameter Sealing,Material (top 501 t t Depth Filler Material (Below 50')--- TYPE 0')- —TYPE OF SEPTIC\WORK: NEW INSTALLATION REPAIRIADDITIDN,1 I1'G(ESTRUCTION I ) (No septic,system permitted if public sewer is Installation will serve: Residence XCommercial Other Number of living units: r Number of bedrooms_ �J sL } Character of soil-to a depth of 3 feet: W Water table depth w t # SEPTIC TANK © Type/Mfg Capacity . No. Compartments t t PKG. TREATMENT PLT. ❑ f Method of Dispo€ 1 ` Distance to nearest: Well sf l.L Foundation Property Line LEACHING LINE ❑ No. & Length of lines ,` f To I length/size f FILTER BED , ❑ Distance to nearest: Well.to Foundation Property Line -. f i SEEPAGE PITS I Depth Size . Number i �� ' SUMPS L] Distance to nearest: Well� Foundation Property Line !v _ ~ DISPOSAL PONDS ❑ �- l f r I hereby certify,tha"t,I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances; state laws, and rules and regulation's of the San Joaquin Local Health DiMrict. Home owner or 46nsed agent's,signature'certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall not employ any person in such manner as to become subject to workman's compensation laws of California.'t Contractor's hiring or sub-contracting signature i F 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' I tion laws of California." f The applicant Vt call for a11; quired in ctions. Complete drawing on reverse side. y §. �/) _ ,�. y Signed X Title: T._.._Q.�(�/ JA.e Date: - FOR DEPARTMENT USE ONLY �'a . r Application Accepted by Date ,/' h �j Area 'a Igor Grout Inspection by a e Final Inspection by Dat t Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 f r' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 PEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT•NO. INFO x a.EH13-24IREV.l/n5Y zzatz .57— / EH 14-2B 4 , I