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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 (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 Y3`Z/ 9L fiLS-Z 3 Al, W/ City 7:�.t/ Lot Size PM 77LP�'E�✓ 4C-A47y Owner's Name .BI.GL .07s72.SA/ Address Phone _ G' -a 3 Contractor_F ate+ ►.t1U491> Addresses Al- 4 JJ 4_,d45/ r License No. i/2-17G Phone -997/ TYPE OF WELL/PUMP: , ANEW--WELL❑---- WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION ❑ SYSTEM REPAIR E OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK AS ER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ATURF WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well'Excavation =" Dia. of Well"-Casing, ❑ Domestic/Private ❑ Gravel Pack 0 Tr Type o asing a ' } Specifications I`l Public 1-1 Other ILA Delta Depth of ut Seal Type of Grout I I Irrigation �..Approx pth I-1 Eastern Surface Seal I tailed by _ Repair Work Done El Type ump H.P, State Work Done Well Destruction ❑ ell Diameter Sealing Material Itop 50'1 G Depth Filler MateriaI)8e10W 50'1 S _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I RFPAIR/ADDITIONg DESTRUCTION l I (No septic system permitted if public sewer is 51;1 available within 200 feet.] IW Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: C [=A-rf Water table depth— SEPTIC TANK ❑ Type/Mfg X fX 2:!Z Al 6- Capacity No. Compartments PKG. TREATMENT PLT. ❑ F Method of Disposal *Distance to Wel! Foundation Property Line r LEACHING LINE No. & Length of lines J Q �Total length/sizes FILTER BED ❑ Distance to nearest: Well ®d z Foundation Property Lined SEEPAGE PITS I Depth A) I Size it Number SUMPS. L1_ Distance to nearest: Well_ CO Foundation Z X"' Property Line A0 5 DISPOSAL PgNDS _"❑ 11"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§trict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this p—ermit is issued, I shall not 1 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,t shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for ail required inspections. Complete drawing on reverse side. + J/ Signed X_C � I.C � t "!u Title: Date: {� FOR DEPARTMENT USE ONLYzbl ' Application Accepted by --r I Date �l Area G Pit or Grout Inspection by Date �O Final Inspection by Date VA Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3(9,3621--:_ ❑ Manteca 823-7104 ❑ Tracy 835-6385 t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201FEE E i INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT"NO. + EH 1324 1REV.t/x 57 EH 1428 l