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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA N Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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. Job Addres J " W�/1 + City Lot Size PM r Owner's Name Address, a 3.2 "' w" J i Phone / • 7 I � r17a_1_1 wQ �' Cc tiacto" ress_ S License iVo. �d - `��Phone� .��Y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f 3: CJI PUMP INSTALLATION ❑ SYSTEM REPAIR LI OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LES DISPOSAVFCb.`--" PROP–`LINE ! ''S I E FOUNDATION AGRICUL URE WELL OTHER vSIELL PITS/SUM`PS F INTENDED USE TYPE OF WELLPROBLEM AREA CON RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation a __Af Dia. of Well Casing ❑ Domestic/Private LIGravel Pack ❑ Tracy Type of Casing v'Specifications M Public (_1 Other ❑ Delta Depth of GSeal ! Type of Grout b Ik rout ; _,I I�Irrigation —.-Approx. Depth I ] Easter Surface Seul'Installed by Repair Work Done ❑ Type of Pump H.P. I 'F State Work Done_ ! Well ] rction ❑ Well Diameter Sealing Material (top 50'1 f`.f estui t ew Depth t Filter Material (Below501r TYPE OF SEPTIC WORK.:L.NEW-.INSTALLATION..I-1,,,_REP_AIR/ADDI..TION-L.l_DESTRUCTION_ (No septic s stem permitted if public sewer is able in 200 feet.) ' Installation will serve: Residence_ Commercia Other .F Number of living units: Number of be ao s 14 Character of soil to a depth of 3 feet: Water table depth •;SEPTIC TANK ❑ Type/Mfg Capacity Na. Compartments Awa 1P EG. TREATMENT PLT. ❑ Method of'Disposal r r Distance to nearest: Well Foundation Property Line r ,LEACHING LINE ❑ No. & Length of lines Totalllength/size i ,FILTER BED ❑ Distance to nearest: Well Foundation Prdperty Line" F SEEPAGE PITS I I Depth Size Number SUMPS ID Distance'to nearest: Well Foundation Property Line DISPOSAL PONDS C7 i�, 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 t certifies the fallowing: "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." [ 4 � The applic t must c. r all requi ed inspections. Complete drawing on reverse side. Signed X r >� Title: ADate: R DEPARTMENT USE ONLY l / Application Accepted by Date b" Area I Pit or Grout inspection by r� -Date Final Inspection by Date t Additional Comments: �la P-. VN 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 FEE)NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. S � rrr..r�� + EH 11-24(REV.riHSr S ' 1 / ' e O ® �U 5 � CS 9 C} _l EH 14-2e ti./ / '-` 7 [ 3 /O l � F