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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELI 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 E 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'Ff S erq w I City 1, 04 Lot Size PM #r 1N�` 3�g-5r5r Owner's Name 7111 lV l/V ery Address _._ N� Pr� G�� Phone 1 I C O5 7 T le St k6V Jr 22l Phone r yg`r3 s Contractor S �efruM ��t Address License fVo. TYPE OF WELL/PUMP: NEW WELLot WELL REPLACEMENT ❑ DESTRUCTION ❑ } PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER NtON s CT-D(Z'l""-N �,u DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 !N� ❑ Domestic/Private ❑ Gravel Pack _ -❑ Tracy Type of Casing i Specifications FI Public *Other ❑ Delta Depth of Grout Seal, Type of Grout&� �. ! I I Irrigation __Approx. Depth 1 1 Eastern Surface Seal Installed by S Uh a - Repair Work Done ❑ Type of Pump H.P. State Work Dope,_ e Well Destruction LJWell Diamete#fr �QCIL4 Sealing Material (top 501 Gaol �iVfyNl r Depth _&0t -Pef Filler Material (Below 501 6,+A.)d TYPE OF SEPTIC-WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTION.[ 1 INo septic system permitted if public sewer is r available within 200 1eet.1 Installation will serve: Residence Commercial Other ' i Number of living units: Number of bedrooms ti..1 Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Z�_ PKG. TREATMENT,PLT. ❑ Method of Disposal l" Distance to nearest: Well Foundation Property.Line M LEACHING LINE .. ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 'J I hereby certify that t 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, 1 shall ncm I employ any person in such manner as to become subject to workman's compensation taws 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 applicantVnust call for all re a cti ns. omplete drawing on reverse side: I a . Signed X Title Fyf0aoz,lac. +19 Date: `r f FOR}DEPARTMENT.USE ONLY Application Accepted by `L Date Z4 19 7 Area �j l Pit or Grout Inspection by # Date Final Inspection by Date/3 Additional Comments: W m� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 L Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE �1 INFO AMOOU(N'}T DUE] AMOUNT REMITTED CK RECpEIV�ED,13Y, DATE r PERMIT'NO. +.EH 1324IREV.1/H51o l laol ,/,/,� R'7r�f . .EH 14-28 - ✓ V'"' !J G'iC