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- --- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` }-.,, 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED . .:,. s ,- (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 +r Local Health District— `' 1 •[L/Jt/. P e V �. Y .J !Job Address -rf-�'�� }':� City Lot Size �PM__ Owner's Name r►' �Ca` R {` tiAdress ! `7`, k''3�( *! Phone Contractora� 3 .0 r Address icense No. Phone TYPE OF W UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ � PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: S TANK SEWER LINESDISPOSAL F PROP. LINE FOUNDATI AGRICULTURE WELL WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR AREA C CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack acy Type sing Specifications LJPublic ❑ Other ❑ Delta Depth of Grout Type of Grout { ❑ Irrigation rox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ype of Pump H.P. State Work Don _ ! Well Destructi ❑ Well Diameter Sealing Material {top 50') - Depth Filler Materia! (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTioN (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence_ Commercial_ Other ; Number of living units: r Number of bedrooms Character of soil to a depth of 3 feet: }` ; r Water table depth SEPTIC TANK )< Type/Mfg 3 Ca acit p Y s_No. Compartments PKG. TREATMENT PLT. ❑ s p Method of Disposal Distance to nearest: ,Well Foundation Property Line f i LEACHING LINE U" No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 3 i SEEPAGE PITS Depth iSize 1 Number SUMPS EV.-Distance to ne.are t:; Well Foundation Property Line { DISPOSAL PONDS ElF t n ] hereby certify that I have prepared this application and that the work will be done.iri accordance with San'Joaquin county ordinances, state laws, rules and regulations of the San Joaquin Local Health'District:"�--- t; �. _ _and ,' Home owner or licensed agent's signature certifies the following: "1 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 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.". t 4 The applicant must call for all required inspections. Co lets drawing on reverse side. i t Signed X � (3-91.c�-�� # - Title: 1 ;Date: 3 {3 h a TM FOR DEPARTMENT USE ONLY Application Accepted by Date Ar s VtAa rtr• �� J� j Pit or Grout Inspectio b / Date Final Inspection by Imt 0, Date 3 l3 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 635-M Applicant- Return all Copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9x52001{ l� �W ,q,� Sr `[9 C4`LPO ��i` lµ5 � ( �VI vla ism s�o woe �.P. �4�5 l?b[`tieJFEE C/ INFO AMOUNT DUE F AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. -i + L 41'l + EH 13-24'I REV.17 H 51 ji.ti O`� S• lL/a p c/ "� Q f 7 EH 1428 ..+-.„. / _ .-w. _...... .._... ..�. . ` r