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APPLICATION FOR PERMIT : Ac SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE i ON AVE., STOCKTON, CA # Telephohe (209) 466-6781 PERMIT EXPIRES TY>EAR FROM DATE ISSUED Womplete 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District., t 2 r� Job Address k9,30 Ew&0'_O Cit Lot Size 417'X /00 rPM Owner's Name ` 1 e t e�'��__ Address oC ��SPhone qla 3 4 d r el FE Contractor >�[ Address License No. Phone_ 3 0�Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ w PUMP INSTALLATION ❑ SYSTEM RE ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROHL A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ M eca Dia. of Well Excavation Dia. of Well Casing - ❑ Domestic/Private ❑ Gravel Pack Tracy ype of Casing Specifications I'l Public n Other F1 Delta De of Grout Seal Type of Grout I I Irrigation _..Appro In I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump: H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material 18elow 501 n� TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION i 1 DESTRUCTION (No septic system permitted if public sewer is I I available within 200 feet.) tt Installation will serve: Residence—3 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 'r] Distance tot'nearest: Well Foundation Property Line I J LEACHING LINE ❑ No. & Length of lines Total length/size ff FILTER BED ❑ Distance toy nearest: Well Foundation Property Line 1 I SEEPAGE PITS i I Depth ) Size _ Number SUMPS L1 Distance to nearest: Well Foundation Property Line ` DISPOSAL PONDS ❑ 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 f 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 F 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 applicant must call fo l requspections..Complete drawing on reverse side, ` p� j Signed Title: - 14) Date: ! _f 9 it FOR DEPARTMENT USE ONLY Application Accepted by s Date Area / Pit or Grout Inspection by Date Final Inspection by Aiw��s,,,_, Date f b-041 Additional Comments: .. �.�0 a c ��' �Gl�12/K �� < S- ;4 ❑ Stk 466-6781 ❑ Lodi 369-3921 Ll Manteca 823-7104 ❑ Tracy 635-6385 � - Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k FEE AMOUNT DUE r AMOUNT.REMITTED RECEIVED BY DATE PERMIT"N0. [�� +.EEH H 14.26 IAEV.i i H 5Y )NFO i. V -! 77 1