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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES .1 YEAR FROM DATE ISSUED t (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. Job Address 19Y7:. City Lot Size PM Owner's Name -`"' �z !1L_C'�� 'Addre_ss' qD� 5 � 4S4/f{ZPhone 3 i l t Contractor Address �,�� -f ense No.3� s yr-Phone 141-5136 TYPE OF WELL/PUMP: NEW WELL ❑ -WELE REPLACEMENT ❑ `t'IDESTRUCTIO PUMP„INSTALLATION ❑ r SYSTEMA REPAIR ❑ ry "OT# Efi fl - ` - - { DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ~- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL ,PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 'Open Bottom []'Manteca Dia. of Well Excavation Dia. of Well Casing I. IV F-1 Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications i`l Public Other ❑ Delta” Depth of Grout Seal Type of Grout I I Irrigation E 't�pprox. DeptW-4-.I:�Eastern, ;'?Surface Seal Installed by Repair Work,Done 0 Type of Pump 9 H.P. State Work Done_ Well Destruction Well Diameter ,_Sealing Material )top 50'1 " Depth: Filler Material Welow 50') f TYPE OF SEPTIC WORK: NEW INSTALLATION I I R�-I'AIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence , Commercial Other Number-of living units: i � i �g u, � �Number of bedrooms-, Character Of'soil to.a depth ofk feet: " i Water table depth 4� SEPTIC TANK .❑ Type/Mfg apacity No. Compartments t� PKG. TREATMENT PLT. ❑ Method of Disposal I_ Distance to nearest: Well Foundation Property Line Ilk LEACHING LINE ❑ No. & Length of Ii Total length/size v FILTER BED ❑ Distance ton est: Well Foundation Property Line SEEPAGE PITS i I DepthSize — Number SUMPS CI Dis ce to nearest: Well Foundation Property Line DISPOSAL PONDS C1 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. _ 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 shalt 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,1 shall employ persons subject to workman's compensa- tion laws of California. The applicant m s 'll-re ired ins ' ns. Complete drawing on reverse side. I Signed X Title: -�a Date: 2.L r 10111, FOR DEPARTMENT USE ONLY Application Accepted by __ Date 31 ` ) Area Pit or Grout Inspection by 1-01 Date Final Inspection by Z047PI Date —— Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies.to: Environmental Health Permit/Services 1601 E. Hazelion Ave., P.O. Box 2009, Stk., CA 95201 N tFEE CK 0 �J ' INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY fffDyyyATE �PyERMIT�''N(o�.! +.EH 13-21[REV.i/n 51 EH 11-26 0^ Q! ((