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!� OU APPLICATION FOR PERMIT �`J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 Address ® 0 j M J • Cits rt- Lot Size PM Owner's Name `�" d4bAddress r D lY / // V Phone Contractor's Name c l_a r K W FI-1— Li se No. 171 in Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAL SYSTEM SYSTEM REPAIR ❑ F)H R 4 DISTANCE TO NEAREST: SEPTIC TANK/=sem- SEWER LINES DISPOSAL FLD.Z�/a PROP. LINE ` Ft?, TJON ASMOATURE WELL OTHM WELL PITS! INTENDW U TYPE OF WELL PROULIaM AREA CONSTRUCTION SPECIR! ❑ I�ndu ❑❑� � ❑ Die. of VM Excavactionn Via. of WUI Casin C!'Dar►Mdc1*k_ita C'YG-ravel Pack ❑ Tracy Type of Casing_S TL"( L-. Spec =tions /2 ❑ pylic ❑ Other ❑ Delta Depth of Grout Seal—� Type of Grout G7 --Approx. Depth W Eastern Su ace Seal Installed by /I AQ Work Done,. ❑ Type of Pump /-� H.P. State Work Done VV4,DDestruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑.(No septic system permitted if public sewer is available within-200•-feet.) Installation will serve: Residence_ 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 Distance to nebrest: WetF- Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS M Depth Size Number SUMPS O; Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, 1 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." The applic m St r al s tions. Complete drawing onr vers /e side / Signed Title: 1("'1 `A / Date: ( V FOR DEPARTMENT USE ONLY Application Accepted by _ Date�_< S� �/ Ar a GiPpu�-O C,� Pit r rout pection byJA-70" �a Date Final Inspection by Date � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environfnonjal 1460t1hiMermit/Services 1601 E.-Hazelton Ave P.O. Box 2009, Stk., CA 95201 CKV FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMWISIO. + EN 13-241REV.10/83} EH 14-28 ©C3 1 O✓ •S` �S l,3�