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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i i 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y (Complete,in Triplicate) Applicatiob 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address City QKCt Lot Size' 9:2Z?&rS PM Owner's Name (it/fi[rr{�iu l/l1/� Address -_/ r_�• ��iY ��flJ ^��1l'[AG( Phone - ,c� $ Contractor Address_ License No. Phone % TYPE OF WELL/PUMP: NEW WELL-❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑: OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done f(� Well Destruction ❑ Well Diameter Sealing Material (top 50') V� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if.public sewer is: available within 200 feet.) Installation will serve: Re idence Commercial_ Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 171 Type/Mfg —_ YV[Lk;i' Capacity No. Compartments PKG. TREATMENT PLT. ❑. Method of Disposal r ,t Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Q F/+ tal length/size FILTER BED Distance to nearest: Well�.__ Foundation Property Line i SEEPAGE'IPITS ❑t Depth 11A ell d o Size Number rf SUMPS r Distance to nearest:, Well Foundation Property Line j DISPOSAL PONDS ❑ M 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 �egulations of the San Joaquin Local Health District. i 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." Contractors hiring or sub-contracting signature certifies thb following:"I 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 mu t call for all require inspections. Complete drawing on reverse side. Signed , Title: _ (1��f�/1� Date: �3 FOR DEPARTMENT USE ONLY Application Accept4d by w Date _ Area Pit or Grout Inspection by ,( Date Final Inspection by Additional!Comments: es+ if/ IP/ 6 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 II FEE AMOUNT DUE NFO AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. I I + EH 13-24(REV.IAa5) fCp EH 14-28 �� S �a o g$r_> "Otti iz