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3 ��' APPLICATION .FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 01V 1601 E. HAZE'S 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. Job Address + �� A �6�2&1k_1E 2Q City Lot Size PM Ale Owner's Name Ilv �/V Address !/ cKJ �7/V/17. 4,4 Phone CDntractos Address /�� /�f� X+ License No. j�Phone TYPE OF WELL/PUMP: CAEW WELL :; y t WEL�L`.�REPLACEMEIVT ❑ DESTRUCTION ❑ PUMP INSTALLATI ? SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST:_ SEPTIC TANK SEWER LINES _ DISPOSAL FLO. PROP. LINE �J f FOUNDATION AGRICULTUREJWELL OTHER WELL,. — PITS/SUMPS INTENDED USE TYPE OF WELL PROBL IM AREA CONSTRUCTION SPECIFICATIONS JA ❑ Industrial ❑ Open Bottom ❑ Mant ca Dia. of Well Excavation Dia. of Well Casing104 Domestic/Private Gravel Pack ❑ Trac."`— t^ --+*e of Casing Specifications ✓ M Public 1-1 Other Cl Delta' Depth of Grout Seal Type of Grout I i Irrigation :ZwApprox, Depth I I Eastern Surface Seal Installed by CAL= _ Repair Work Done ❑ Type of Pump H.P. _ State Work Done Well Destruction ❑ Well.Diameter Sealing Material atop 50'I 1 Depth s Filler fylateriall(Below 50'i -�J TYPE OF SEPTIC WORK: NEW INSTALLATION I I [,REPAIR/AIaDITION l 1 DESTRUCTION I 1 (No septic system permitted if public sewer is r # g j avadSble�within 200 feat.) Installation will serve: `Residence Commercials Other/ �r Number of living units' Number of bedrooms.__... t Character of soil to a de tfi,ff p bf;3 feet: r ! I Wate'r'zs b depth _ f SEPTIC TANK ❑ Type/lUlfg r=1 Capacity. No.Compartments PKG. TREATMENT PLT. ❑ r Method'of Disposal Distan a to nearest; (Well __)k undation Property Line 1 � LEACHING LINE ❑ No. & Length of lines ! } Total length/size FILTER BED ❑ Distance to nearest: 'Well Foundation \/f _ Property Line SEEPAGE PITS ��'.ls� 17Dep1h; F7^. Siz�_ r J�Nurrlber SUMPS Ll Distan a to ne&est'= Well Foundation 'Property Line (� DISPOSAL PONDS ❑ I hereby certify that I`have-prepared this,application tat t the work wi 1'be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. µt_ H6me-owne7 or licensed"agent's signature cemfies-ti) following: "! c`ertify thaLin_the. rformence of'thework•for which.this permit is issued, I shall not employ any person iisuch manner as•to Gecnrne subject to orkman w 's compensation laws of California." Contra`ctor's hiri6o,oi sub-contracting signature certifies the following; "I certify that in the performar�+of the work for which this permit is issued,I shall employ person's'subject to workman's compensa- tion\laws of California--.-71- �• - w� y_ 9 The applicant si re u— its omplete drawing on reversde. gi Signed X '01 a_ Title: Date; r ` fFOR DEPARTMENT USE LY Application Accepted by Date y 4r' Area c72/ v � jj Gro Inspection-11 bye I Data I Q Final Inspection by 'Y�L�' Date dditianal Comments: ❑ Stk 466-6781 - ❑ Lodi 369-3621 �4fk,❑AAsnteca.-823-7104 ❑ Tracy 835-6385 Applicant \Return all copies to.`Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stli., CA 95201 a ve I_t t y� CK 9 FrE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE; f'A q,P,ERM^IVNO. +,EH 13.21[HEV. EH 11-29 �,_._—L'. _ _....16 0,�.. -.ate--t• _ - _ ,.,....,....--.,....�----.-�........ — r,�{J 1 a'1 1 I 1 P