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APPLICATION FOR PERMIT I SAN JOAO. �1N LOCAL HEALTH DISTRICT �0 �L 1601 E. HAZELTO,N AVE., STOCKTON, CA q n Telephone (209) 466-6781 FES PERMIT EXPIRES 'I 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 SanJo uin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. � G�® / /p l rot —o i r J /� �t Job Addr Ity -5�-` Lot Size les/ �`J`C�'C- PM Owner's NameDaus, Address n I Contracto IrS U>~CL� K Address I it g) A' License No.��s� Phone�l�^ -2 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATI N ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Q,�SEWER LINES -_IVM.e DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing o! Qomestic/Private CJWGravel Pack D Tracy Type of Casing-_ f I G Specifications — 1"1 Public Cl Other Cl Delta Oepth of Grout Seal , l T�pe of Grout I I Irrigation _C p9 . Depth l I Eastern Surface Seal Installed by //I/S6& Fll IaS- - Repair Work Done L] Type of Pump H.P. State Work Done 7 (� Well Destruction ❑ Well Diameter Sealing Material (top 50') �1 Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Z 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line \\\ SEEPAGE PITS I I Depth Size Number SUMPS L7 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicap must call for all required inspections. Complete drawing on reverse side. Signed Xt G Title: t$K f.t�-wt Date: FOR DEPARTMENT USE ONLY Application Accepted by Date a ^�e _Area Pit o rout spection by Dat ^r inal Inspection by zv. __., Date' .�, ,�.� •. Additional Comments: IV40 16 o / o sem' �/.�� f / �; �.��•%J.33/—�// LI Stk 466-6781 ❑ L I 369-3621 ❑ Manteca 823-7104 ❑ racy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 RECEIVED BY DATE PERMIT'NO. AMOUNT REMITTED cases