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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 'I'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. ' Job Address a SO Ig City _Sjmsl� Lot Size PM I CA Owner's Name Address 10= " - NZ1jPhone Contractor 7L •i• i se No. Wd Phone TYPE OF WELLIPUMP: NEW WELL Jr, 0M E DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM,REPAIR ❑ �" OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �L/4-__— SEWER LINES DISPOSAL FLD. AI& PROP. LINE FOUNDATION jQ 1 AGRICULTURE WELL _ OTHER WELL PITS/SUMPS AW INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation )� rt Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack LlTracy Type of Casing Z) ID S ko Specifications pq CubOther (-1 Delta Depth of Grout Seal t 'Type of Grout _ IFrig a�t�r t Kv Approxi. Depth I I Eastern Surface Seal Installed by �fLtts tttz_ G Repair Work Done ❑ Type of Pump H.P, State Work Done Q Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth `1 - Filter Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION I I DESTRUCTION 11-INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence�� Commer I Other Number of living units: Number of bedroom i Character of soil to a depth of 3 feet:' Water table depth SEPTIC TANK LI Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance'to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Lehgth of lines Total length/size FILTER BED ❑ Distance;to nearest: Well Fountion Property Line SEEPAGE PITS I l Depth j f Si Number ` SUMPS ❑ Distance•to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1111 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 Di?itrict. 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." v The applicant s call for all r quired inspections. Complete drawing on rovese side. 5&,C- k1V4_ T Sig Title: CaLm"73 Date:_ 09C ( � _ 7 Q r FORD RTMENT 5 ONLY Q' L Application Accepted by -- Date CJ—.„ ,I Area .-... Pit or Grout Inspection by Date Final Inspection b- Datt3C�",arr °7 Additional Comments: ❑ Stk -466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385” Applicant - Return all copies the Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 y . FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE rte} PE R MIT-NO. +.EH 13-24)REV-t/K 51 '4�/s - `-ter /y? EH l4-Ze