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too Ia � • APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT k h 1601 E. HAZEL T ON AVE., STOCKTON, CA y ' Telephone (209) 466-67$1 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. r r a ,� :, 4 f .�' ' s r Job Address City {�ot Size - PM .. �--- �l O Owner's Name d"✓� + ' 77 VJ_#&Address 64 Ath Phone Contractor Address! License No.I'm"Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTI4 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LI-NES_ _ DISPOSAL_ FLD.- _..,PROP..LINE - :.- FOUNDATION AGRICULTURE WELL OTHER PITS/SUMPS q INTENDED U TYPE OF WELL PROBLEM AREA CONSTRU SPECIFICATIONS r i ❑ Industrial Bottom ❑ Manteca of Well Excavation " Dia. of Well Casing L ❑ Domestic/Private ❑ Gravel Pack Trac t yE Type,of Casing Specifications 1— Ll ❑ Public ❑ Other It epth of Grout Seal Type of Grout ❑ Irrigation _Appro epth ITE astern Surface eal Installed by r ` Repair Work Done ❑ Type ump H.P. ❑ State Work Donemow*- ` Well Destruction ❑ ell Diameter tSealing,Material Stop 501 { Depth Filler Material (Below 501 A TYPE OF SEPTIC WORK: NEW INSTALLATION ❑, REPAIRIADDI710N ❑=DESTRUCTION o septic system permitted if.public sewer is (v/1 c available within 200 feet.] Installation will serve: Residence_ Commercial_ Other' Q ��.q. I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: f P = Water table depth SEPTIC TANK ❑ Type/.Mfg s • d Capacity No. Compartments l �- a PKG. TREATMENT PLT- ❑ 3 Method of Disposal Distance to nearest:-- Well i .!.FoundetioWt! Property Line LEACHING LINE ❑ No..& L'ength'of lines � . ^ K � -2 ` Total length/size !� FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS ❑ Depth, �+ t Size "'"r Number j SUMPS ❑ Distancer'to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ :fit.....:..-rd.._ I 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 t.or which,this permit is issued, I shall employ persons subject to workhlan's compensa-tion laws of California," � y4 I The applicant must call for all required inspections. Complete rawing on reverse side. Signed X-90-10. �. :Tifle:"� .� + Date: 0 Ir j FOWDEPARTMENT USE ONLY Application Accepted by Date Area : d :u ,. • r. . t Pit or Grout Mspection by. "' _�. Date Final Inspection by Date Additional Comments: � ✓�^„ J P r. � ^? ""cL�.r d1l� ,/vy�rl w l ry��r< ,. . - ` — •'S ❑ Stk 466-6781 LJ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6G385 �G Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I INFO AMOUNT DUE AMOUNT REMITTED CASArk&K C RECEIVED BY r DATE PERMiT'NO. f f iEEH H13-24(REV,1iHS) �"� IlJ �-7 C