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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT - r 1601 E. HAZEL T ON AVE., STOCKTON, CA z Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED # (Complete in Triplicate) , y 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. k, ,/; W, r Rik. ;.. ! ! AP Job Address e r r ,. City Lot Size /75 X 365 PM Owner's Name JA G'Y14'Q_AL! V Address Phone910 Contractor Xcw_4&q5 i6ra6. Address &925 e . Ad—License No. 9D�'/3 Phone — TYPE OF WELL/PUMP: V NEW WELL'9 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ' •1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /dZ3 SEWER LINES DISPOSAL FLD./00 ' PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA 3 CONSTRUCTION SPECIFICATIONS r. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing 1K Domestic/Private N Gravel Pack CZ Tracy Type of Casing 00 y t4l Specifications DQ IJ Public ❑ Other ❑ Delta Depth of Grout Seal r Type of Grout 44 ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by ^ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 I Y Depth. Filler Material (Below 501 1 n'K�F WORK: MEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (N septic system permitted if public sewer is ' available within 200-feet.) 1• ' t Installation will s Residence_. Commercial_ Other r �— .:Number of living units:' _ -^Nurritier of bedrooms Character of soil to a depth of 3 fee . Water table depth SEPTIC TANK ❑ Type/Mfg Capacity ;No: Compartments PKG. TREATMENT PLT. 0 ! Method of Disposal Distance to nearest: :111undation Property Line' 1 LEACHING LINE ❑ No. & Length of lines I length/sizee\ + FILTER BED F-1Distance to nearest: Well Foundation rty t ine • ti t � r 'i3'., .SEEPAGE PITS .❑ ,Depth 7 Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line , DISPOSAL PONDS Cl 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 ` 1 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 licant ust call for all re uired g pp q inspections. Complete drawing on revers side. , t Signed X Titl Date: 14M a FOR EP RTM ENT USE ONL ,1 t Application Accepted by Date .1 Lo O Area k Pit or Grout Inspection by Date rte_ pe Final Inspection by Date Additional Comments: —//J ❑ Stk 466-6781 ❑ Lodi -3621 If Manteca 823-7104 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CAM + EH 13-241REV.i/66) f� EH 14-28 i