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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 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. �/ ,Q Job Address !` 5771 �V�i A01 me I City Lot Size PM Owner's Name G 411/ e/�/0ll Address . Q//'YU Phone -�1"yw Contractor tCl I C7F-4S'r Address/—Q •✓! L 7 O License No.-I 7731'57 Phone 3y S TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION,X SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � FOUNDATION AGRICULT0FWWELL a OT�iElk WELL .� PITS/SUMPS _ - -44TENDED{JSE TYPE OPWELL-- PROBLEM AREA--. CONSTRUCTION SPECIFICATIOjy,S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation.'400Z Dia of Well Casing *ie Domestic/Private X Gravel Pack ❑ Tracy Type of Casing /CYC Specifications F'1 Public F1 Other ❑ Delta Depth of Grout Seal. Type of Grout gne.%V 4 I I Irrigation _..Appr?x. Depth I I Eastern Surface Seal Installed by C t0 A,T iJC_*PX Repair Work Done ❑ Type of Purnp it, H.P. State Work Done_Cai#.eZ rCW Well Destruction ❑ Well Diatneter Sealing Material (top 501 Depth - - -Fi#erMaterial (Below 501 TYPE OF SEPTIC WORK: NEW INSTAMATION I I REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewet 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 41 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ` PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation-._ Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Cl Distance to nearest: -'"VVtell Foundation Property Line DISPOSAL PONDS ❑ 1 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 Dibtrict. 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 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 for all required inspections. Complete drawing on reverse side. y Signed X / fit!" Title: &JA Date: Z.S'p 4 FOR DEPARTMENT USE ONLY Application Accepted by Date ZT Area Pit or6rCil" tInspection by to final Inspection by Date7�l Additional Comments: O 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 t FEE AMOUNT DUE AMOUNT REMITTED -'W4 I RECEIVED BY DATE PERMIT N0. INFO eArn ♦.EH14-24IREV.t/n5) t�..,30 � 1 � 99— 'L`J�l