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I p APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �C\ 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/of 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. k 1 Job Address ! 1`I j r~S _ City 1 Lot Size PM Myl�E fi �� Phone 36 Owner's Name —144 � � � -^r �ddress5 &6! P � 1 Al_S�cla -2_ iF ti �6p i �..] Contractor � ress License No.9 ?919 L T9 Phone 3jCn 9.3I TYPE OF WELL/PUMP: KNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1-1. PUMP INSTALLATION ❑ SYSTEM REPAIR + OTHER Cl DISTANCE TO.NEAREST: SEPTIC TANK __.SEWER LINES_ rDISPOSAL FLD. f'.R.OP. LINE .; --�—�— F_OUNDAI<ION. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE . TYPE OF WELL r._PROBLEM AREA .,._.CONSTRUCTION SPECIFICATIONS �"y� 0 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,F ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public C] Other 'M' F1 Delta Depth of Grout Seat Type of Grout { IN I �Errigauon —_-Approx. Depth i I Eastern Surface Seal Installed by r Repair-Work'/Done- 13- Type of Pukmp H.P. State Work Done rC C. /77 . ` Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I:] FiFPAIR/ADDITION I I DESTRUCTION I ] (No septic system permitted if public sewer is available within 200 feet.) ' installation will serve: Residence L Commercial_ Other , Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments p PKG. TREATMENT PLT. ❑ 11! Method of Disposal Distance to nearest: Well Foundation Property Line IM. Y LEACHING LINE ❑ No. & rength of'tines Total length/size , FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number �>♦ '- SIiMPS—� L� Distance to W-rieaiest' WaIkY=�—= �Foundation - -=,.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 coup i laws, ander' rules and regulations of the San Joaquin Local Health Diltrict. ,� % Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which t 1 I shall not employ any person in such manner asGW become subject to workman's compensation laws of California." Contractor's hin I N su n�g signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons so lectto• k an s compansa- tion laws of California." !�, SAN JOAQIJIN COUNTY The applicant must call all required inspections. Complete drawing on reverse side. PUBLIC KALT'H SERVICES �l ENVIR N{th N'71.J L1 -0r•i Signed X Title: ate: FOR DEPARTMENT USE ONLY Application Accepted by _ Date Area Pit or Grout Inspection by IA� Date Final Inspection by Date C1 Zg Z Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Envir�o nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUIE AMOUNT REMITTED K RECEIVED BY O TTE PERMITT''NO. +.EH 13-24(REV.1/145) -7 EH 14-28 111��` � (�✓ ,(/J