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APPLICATION FOR PERMIT VN ! 7� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE-JON AVE., STOCKTON, CA Telephone (208) 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.TMs 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. ,p 1. Job Address 5f 9 P VjQZ_,!5-�� _46 -- City - ' Lot Size PM Owner's Name Address —5e1221:95: Phone II Contractor's Name JO License No. `s Phone -V-3 g� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑,� DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ti} OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELD 1• - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT10N41F`ECIFICATIONS ❑ Industrial yl 1.�� Open Bottom ❑.Manteca_''or Dia. of Well_Excavetion _ Dia.of Well Casing ❑ Domestic/Private ❑'Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Others ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by nfJ Repair Work Done ❑ Type of Pump H.P. State Work Done LAJ Well Destruction © Well Diameter Sealing Material Itop 501J Depth Filler Material {Belo '1 # U TYPE OF SEPTIC WORK: NEW INSTALLATION i] REPAIR/ADDITION • DESTRUCTION ❑ (No septic system permitted if public sewer is1 ' available within 200 feet.l_J ry Installation will serve: Residence Commercial Other e 3°iT Number of living units: Number of bedrooms Character of soil to a depth.of 3 feet: 'Watar-table depth I SEPTIC TANK 13Type/Mfg Capacity—. .No. Compartments--' PKG�TREATMENT PLT. EJ _;_ ° s; �Methodrof Disposal Distance to nearest: Well j`Foundation �Property-Grie-�- LEACHING LINE No. & Length of lines r? 6 ri t' R Tatal lengthlsize FILTER HED ❑ Distance to nearest: .,,Well - 1 Foundation r Property Line'_` SEEPAGE PITS Depth - 110 Size j- � }�_ _ .._. Number SUMPS Distance to nearest: Wel! Foundation Property L"ine' 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 I`bj rules and regulations of the San Joaquin Local Health,District. t -�"4�'-, I, , 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,.4 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 per mi Wis issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call.for all r aired inspections Complete drawing on rfaverse side. Signed X Title: =�4__ Date: 2__ _10, 1 FOR DEPARTMENT USE ONLY Application Accepted by ^ Date Area D , Pit or Grout Inspection by 3 Date Final Inspection by 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 "FEE" —*AW6NT bUE AMOUNT RETT MIED SASH RECEIVED 9Y OATf~ PEWifAb"' INFO '. + EH 13-24 IREV.10183! e ' EH 14-28 O �"� 5