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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. I-IAZELTON 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. f Job Address `r' 'f! - h 4-e- rpCity a 61 Lot size QPM Owner's Name -ce flee. Address P� O- Q�� -79 G 5441011 Phone J3 O�2 a 83 Contractor_ 1'l Q l' ! I ]1 r tne Address_s Reed RUdid, oa kdQIC License No. s Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION �A SYSTEM REPAIR ❑ OTHER ❑ l hI DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r DISPOSAL FLO. — PROP. LINE J w FOUNDATION AGRICULTURE WELL OTHER WELL — PITS/SUMPS '� \ INTENDED USE TYPE OF WE ROBCt c7ztntn=— ISTRC_T.IL�N.-SPECl1 UCAT_IONS _ -T-- sl ❑ Industrial ❑ Open Bottom ❑ Manteca Ria- of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing f Specifications �,, 1 ,t~'f's FI Public Ll Otherj Cl Delta Depth of Grout Seal f 1�� Type of Grout Oc►t fDN c_. I I Irrigation /J/7Approx. Depth 11 Eastern Surface Seal Installed by _ Repair Work Done LJ Type of Pump 3 H.P. 1 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 AEPAIRIADDITION I I DESTRUCTION [ I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 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. ✓it Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS Cl 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 of sub-contracting signature certifies the following: "t certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California' The applicant utrf call for all required inspec'o s. Complete dr 'ng on reverse side. Signed X Title: 2�T. I7'! _ Date: V LJ :art F REPARTMENT USE ONLY G�'] Application Accepted by ' N. Date ' v`�~9 rea 0 Pit oG out spection b Date Final Inspection by Date/a Additional Comments: A1.3e+ ❑ Stk 466-6781 ❑ i -3621 ❑ Manteca 823-7104 ❑ Tracy 835-63A Applicant . Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 (NEO AMOUNT DUE AMOUNTREMITTEDCK RECEIVED BY DATE PERMIT'NO. EK 13-24(REV.tinsi X. e EH 14-2fS