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�ot APPLICATION FOR PERMIT / SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA I n� 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. 5g3cj Job Address ��L M i`A�. 7 City-Zac4t Lot Size PM Owner's Name -ie C n rn <;�( dd_`), �� .I[ � e-` / j / a' Address a /,O� � l 1 e- Phone Contractor /. 1 nii 116� Address TYPE OF WELL/PUMP: moi- _License No. '8_)Phone L NEW ELL WELL RE-PLACEMENT.❑ PUMP INSTALLATION �. --- DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANK .� SYSTEM.REPAIR ❑ OTHER El SEWER LINES — DISPOSAL FI—DIPROP. LINE FOUNDATION AGRICULTURE WELLf OTHER WELL PITS/SUMPS I � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation � Domestic/Private El Gravel Type of Casing Gravel Pack Dia. of Well Casing 33 ��{ M Public Ll Other F] DeltaSpecifications ,Depth of Grout Seal _ T„�„„f r ut I I Irrigation Approx. Depth .I I Eastern / ,`�lj"'�"-� l7 Repair Work Done ❑ Type of Pump H P j IS"- kSeal Installed by L�i Well Destruction ❑ Well Diameter l-- ^ State Work Done_ Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION f 1 (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity_ _ No. Compartments Distance to nearest: WellFoundation Method of Disposal Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: WellTotal length/size Foundation Property Line SEEPAGE PITS I 1 Depth Size_ SUMPS Cl Distance to nearest: Well Number DISPOSAL PONDS El Foundation Property Line 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 Di$trict. 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 p 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." P The applicant must call for all required inspections. Complete drawing on reverse side. Signed X title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or ro Inspection by i � - Dat �FinalInspection by Additional Comments: ❑ Stk J466-6781 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. ♦.EH 13-24(HEV.I i x s) I r l EH 10.26 Tel- 1�(i�y a) "O 6`9 l O-R