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r APPLICATION FOR PERMIT 6�3 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781: PERMIT EXPIRES TYEAR 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. 1 I Job AddressS "9n� � City/ G �at Size PM Owner's Name G Co? ¢ (/J�O o{ — �y��X S ��lo C�l'�� f��o�03 Phone F/ { 'T f/A n Address Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARES NK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION RICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM REA TRUCTION ECTFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Diia�o�We ation Dia. of Well C_as_ing . 171 Domestic/Private ❑ Gravel Pack El Tracy "Type of Casing Specifications . [-I Public ❑ Other t l�elt� Depth of Grout Seal 4 Type of Gro t i I Irrigation .__._Approx. Depth l l Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION € I DESTRUCTIO (No septic system permitted if public sewer is +� 1 available within 200 feet.) Installation will serve: Residence_ Commercial_-- Other r 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth 3 Size Number SUMPS L1 Distance to nearest: Well 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 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 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for all req iced inspections. Complete drawing on reverse side: Signed X Title: Date: -� �FO;EPARTMENT USE ONLY Application Accepted by 444 X Date 0— r4FZ Area d Pit or Grout Inspection by D Final Ins action by Date Additional Comments: D l�afrI ti✓ �/f0/ �+'/r�/r?/d ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ew �pG4 0YJ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DA/TE_G PEERMI 'NO. < + EH 1a261REV.t/r+57if I � / 3CJrG yvYy 0r o� �J �pv